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0 a <br /> S—AN.)JOAQUIN <br /> Environmental Health Department <br /> COUNTY— <br /> l <br /> Cr - nrows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance With San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address CITY OF MANTECA RIGHT OF WAY-ROSE LANE citylstate/zip MANTECA, CA 95337 Phone <br /> Cross Street GOODALE COURT APN <br /> Property owner* CITY OF MANTECA Phone <br /> Address 1001 WEST CENTER STREET City/state/zip MANTECA, CA 95337 <br /> C-57 Contractor GULF SHORE CONSTRUCTION SERVICES License# C57-964224 Phone (916)9394117 <br /> Address PO BOX 1501 Cityistate/zip SHINGLE SPRINGS, CA 95682 <br /> Consultant/Sub-Contractor AGE License# 680227 Phone (209)467-1006 <br /> Address 837 SHAW ROAD cityistate/zip STOCKTON, CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BodngsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> P9 MONITORING i ® HOLLOW STEM BORING DEPTH 65' ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS SCHED.40" TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ®No Baring Dia: Casing Dia: 2" Casing Depth: 65'-50' <br /> ❑ INJECTION(Airaoaoe.Ozonel ❑ HANDAUGER GROUT SEAL DEPTH 45' TREMIE TYPE TO BE USED: 0AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? IR Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING IDs MW-14 GROUT SPECIFICATIONS _ _PORTLAND TYPE II <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of_feel <br /> WELL IDs []PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS E]EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 28 AUGUST 2017;WATER WILL BE DISPLACED USING A PVC DIVERTER ATTACHED TO THE AUGERS <br /> PURGING WATER INTO 55-GALLON DRUMS,VACUUM ON STANDBY <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> ,n $ap Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed L-4 Title/Company STAFF GEOLOGIST/AGE <br /> Print Name ERIN ROTTACKER Date 18 APRIL 2018 <br /> DEPENT USE ONLY <br /> Application Accepted By: Dale Issued: V?- I lj!� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name S c,V-,L o cxv'� FA Address 1 'V qo _ 1 ., 4 <br /> FA# (902 2 S-q 9 PR# o <br /> FA PE �6 WP Remmed By L -x Work Plan Date &- a0 l-) <br /> [IC-57 57 Authorization forOmer to Sign Permit orkees Comp El Workers Comp Waver Encroachment Permit ❑Access Agreement ERIad Agency ApprovalFR <br /> COMMENTS/CONDITIONS: r_r vjdr.,✓ U 2�.(Artf. ('Vr „J>,.4q'✓ 1i1e 6�_ GltA>fJA" <br /> WP TYPE I PE I SC I FEE INFO AMT REMITTED C.HrHEECK# RECV'D BY DATEWELL PERMIT# INVOICE# <br /> Permit DI -3I $152x ,$ L5Z Z1N'J 3I1�/D Wje <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 j www�jcehd.com <br /> EHD29-01 OMl-17 Site MINgatiw Well Permit Application <br /> �f� zga3 sz3 $�sz�3 �� vtaas -Y 5IzI�� s>~0101QolioH <br />