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• a SAN,IOAQUIN Environmental Health Department —COUNTY— ]rows 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 MANTECARIGHTOFWAY-TIDEWATERBIKEPATH City/State/Zip MANTECA, CA 95337 Phone Cross Street CENTER STREET 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)9394117 Address PO BOX 1501 City/State/Zip SHINGLE SPRINGS, CA 95682 Consultant/Sub-Contractor AGE License# 680227 Phone (209)467-1006 Address 837 SHAW ROAD City/StatelZip 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 115' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOILBORING 1 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes 0 N Bonng Dia: Casing Dia: Casing Depth: ❑ INJECTION fAk Soarae.ezaaet EI HANDAUGER GROUT SEAL DEPTH 115' TREMIE TYPE TO BE USED: CO AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? I@ Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs P-16 GROUT SPECIFICATIONS PORTLAND TYPE II DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of_fmt below surface GROUT SPECIFICATIONS [I 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 I am authorized to complete this application and that the work will be done in accordance with Sain Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed n� Title/Company STAFF GEOLOGIST/AGE Print Name ERIN ROTTACKER Date 18 APRIL 2018 DE ;4 TMENT USE ONLY Application Accepted By: Date Issued: h ha Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name � - � FA Address "l 2 t„f FA# 0102-1su f PR# 7 3Z'3 FA PE WP Reviewed By I L X Work Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver C9 Encroachment Permit ❑Access Agreement L'9't'ead Agency Approval FR COMMENTS/CONDITIONS: " ' N N L S ��' S I _ r x vS f 4 �l `^""Vt WP TYPE PE SC I FEE INFO JAMT REMITTED CHEEC.KK#I RECV'D BY DATE WIC ELL PERMIT# INVOE# Permit OS 313 $152x 15Z �J.I WL) 3 6 Wt pCL 3�LIZ 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 0a-01-17 Site Mitigation Well Permit Application