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SQ N J QQ Q Q N Environmental Health Department I, COUNTY �gerr. 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 Addlress I Shopping Center, Mountain House ICity/State/Zip ITracy, CA 95391 1 Phone Cross Street I Byron Road and Mountain House Parkway APN µ - 030 &dr208-631-480-1-7 Property Owner* Albertsons Companies r'e'v`" P Phone Address 1250 Parkcenter Boulevard City/State/Zip Boise ID 83706 C-57 Contractor Cascade Drilling License# 11058336 1 Phone 925-849-6970 Address 11641 Challenge Drive City/State/Zip Concord, CA,94520 Consultant/Sub-Contractor JENGEC, Incorporated License# Phone 925-866-9000 Address 2010 Crow Canyon Place, STE 250 City/State/zip San Ramon, CA 94598 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 feet and 18ft BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) Q❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8"and 2" 1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N SOIL BORING �S1 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No Note:Maximu Freefall Deis is 30 Ft WELL/SOIL BORING IDs GROUT SPECIFICATIONS �+ r DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 12 E�OVER-BORE DIAMETER of=inches to depth of 20 I feet WELL IDs 1-GW1,1-GW2 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE El PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Because groundwater wells will only be open for 48 hours and will be abandon after that period. �'! JA�Q 1 We confirmed with SJCEH(Jeff Wong)that we do not need to put groundwater wells as r v�.• / monitoring wells,to put them as borings. tJ a 1 hereby certify that I am authorized to complete this application and that the work will be done in Aco r1th San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Z ,)4,y !./fi &1 f/ Title/Company Prniect manager Print Name Dustin King 61 Date 9-15-2020 17 ''^^ DEPARTMENT USE ONLY �f Application Accepted By: V 1 Date Issued: Vv Vv Grout Inspection By/Dates: O I S l Zo Destruction Inspection By/Dates: Facilit /Site Information FA Name AAddress / FA# R# zZ 7— FA PE 2 I WP Reviewed By Work Plan Date -57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ?❑MFR COMMENTS/CONDITIONS: ( ��/ /' u S �(? �iLHI" ��`p',,`s� L j �' S ( ?• T l}�ya {�i/tAQ_ s� QG ti dov�Jrl ► pl i'� n' '� S WP TYPE PE SC FEE INFO J AMT REMITTED CHECK# RECV'D BX DATE WELL PERMIT# INVOICE# PermitZq4 W$1152 x (,� Gr GP V406 4129 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2M1 08-01-17 S�Sit Mitigation Well)pltApplication