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SAN 10AQUIN Environmental Health Department —COUNTY— °g rP Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address CITY OF MANTECA RIGHT OF WAY-ROSE LANE citylstatelzip MANTECA, CA 95337 Phone Cross Street GOODALE COURT APN Property Owner- CITY OF MANTECA Phone Address 1001 WEST CENTER STREET City/State/Zip MANTECA, CA 95337 C-57 Contractor GULF SHORE CONSTRUCTION SERVICES License# C57-964224 Phone (916)939-4117 Address PO BOX 1501 City/State/Zip SHINGLE SPRINGS, CA 95682 ConsultanUSub-Contractor AGE License# 680227 Phone (209)467-1006 Address 837 SHAW ROAD City/State/zip STOCKTON, CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 90, ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA,OF BOREHOLE 8.28' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ZI SOIL BORING 1 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boling Dia: Casing Dia: Casing Depth: ❑ INJECTION rAk soeroe.azonet D HANDAUGER GROUTSEAL DEPTH go' TREMIE TYPE TO BE USED: ®AUGERS El HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes D No (Note:Maximum Freefall Depth is 30 Ft) WEW SOIL BORING IDs P-21 GROUT SPECIFICATIONS PORTLAND TYPE II DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs El PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: SEE WORK PLAN DATED 28 AUGUST 2017:WATER WILL BE DISPLACED USING A PVC DIVERTER ATTACHED TO THE AUGERS PURGING WATER INTO 55-GALLON DRUMS,VACUUM ON STANDBY I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with _ Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed � Title/Company STAFF GEOLOGIST/AGE Print Name ERIN ROTTACKER Date 18 APRIL 2018 DERAIRTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili (Site Information FA Name S e e_ C A � FAAddress Lf 2-0 � Y�,�,x�L FA# �Di>ZZ3S kLk PR# 14 z-3 z3 FA PE �; WP Reviewed By (� X Work Plan Date ❑C-57 G57 Authonzabon for Other to Sign Permit orkees Comp ❑Workers Comp Waiver Encroachment Permit ❑Access Agreement ead Agency Approval 1314R COMM,ENTSICONDITIONS: MP v_v*,/ LS tµGo {�' ,� S�wJ1A d� µZn k..r{SMAt evee_ WP TYPE I PE I SC FEEL INFO AMT REMITTED CHECK# RECV-DVOI BY DATE WELL PERMIT# INCE# Permit _-Ad!;_-Ad!; 31"j $152, ` 4tsz 2_ FEE L– / S-/3118 U r' Uo3 - 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 o6-01-17 Site Midgabon Well Permit Application