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SANoJQAQUIN Environmental Health Department <br /> ---COUNTY— RECEIVED <br /> -1 Greatness grows herr. <br /> APR 18 2018 <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and RemediatioWMRONMENTALHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 City/StatelZip MANTECA, CA 95337 Phone <br /> Cross Street GOODALE COURT APN <br /> Property Owner` CITY OF MANTECA Phone <br /> Address 1001 WEST CENTER STREET citylStatelzip MANTECA, CA 95337 <br /> C-57 Contractor GULF SHORE CONSTRUCTION SERVICES License# C57-964224 Phone (916)939-4117 <br /> Address PO BOX 1501 City/State/Zip SHINGLE SPRINGS, CA 95682 <br /> Consultant/Sub-Contractor AGE License# 680227 Phone (209)467-1006 <br /> Address 837 SHAW ROAD CltylState/Zip STOCKTON, CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ZI HOLLOW STEM BORING DEPTH 115' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(vaporlwater) El HAMMER/DRIVEN DIA.OF BOREHOLE 8.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING 1 ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soeme.0zmnt ❑ HANDAUGER GROUT SEAL DEPTH 115' TREMIE TYPE TO BE USED: IRI AUGERS El HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth Is 30 Ft) <br /> WELL/SOIL BORING IDS P-16 GROUT SPECIFICATIONS PO F ��' T Dp 11 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUC' <br /> #WELLS TO BE DESTROYED ❑OVER-B, ith of_feet <br /> WELL IDs ❑PRESS( ' f face <br /> GROUT SPECIFICATIONS ❑EXPLO' rx suriace <br /> TREMIE TYPE TO BE USED [--]AUGERS ❑HOSE ❑PIPE ❑MUSHF feet below Surface if>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 28 AUGUST 2017;WATER WILL BE DIS ��� .GRED TO THE AUGERS <br /> PURGING WATER INTO 55-GALLON DRUMS,VACUUM ON STAI• <br /> 1 hereby certify that l am authorized to complete this application an..-._ �- cordance with <br /> 1^, Amn Joalquin County Ordinance Codes and Standards,and all other appu.,.....- laws. <br /> Signed ' cA LIn(n � Title/Company STAFF GEOLOGIST/AGE <br /> Print Name ERIN ROTTACKER Date 18 APRIL 2018 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Dale Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili ISite Information ./ <br /> FA Name S � `� ^S FA Address 1� � pN FA# O 2.SS ;gyp PR# <br /> FA PEy(a j WP Reviexed By L - -A Work Plan Date �J•L�l I -7 <br /> 0C-57 C-57 Authorization for Other to Sign Permit ER"Nonees Comp ❑Worker's Comp Walver SIncroachmentPeri ❑Access Agreement 11-t5eead Agency Approval 6;1,1FR <br /> COMMENTS/CONDITIONS: <br /> WPTYPEj PE SC I FEE INFO JAMT REmiTrEDj CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHO 29-01 08,01-1] Site Mitigation Well Permit Application <br /> vie apw-1 s>� zvUr; s(� It� <br />