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SAN,JOAQUIN Environmental Health Department <br />C U N <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 49 East 11th Street City/State/Zip Tracy, CA, 95376 Phone (661) 904-2133 <br />Cross Street North El Portal Avenue ApN 233-369-13 <br /> <br />Property Owner* Levand Family Trust - Paula Levand-trustee <br /> <br />Phone (661) 904-2133 <br /> <br />Address 24692 Sand Wedge Lane City/State/Zip Valencia, CA 91355 <br />C-57 Contractor Slagle Drilling Corporation License# 1046151 Phone 916-363-9355 <br />City/State/Zip Rancho Cordova, CA 95742 Address 11345 Trade Center Drive <br />Consultant/Sub-Contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br />Address 837 North Shaw Road City/State/Zip Stockton CA 95215 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />TYPE OF WELL/BORING <br />0 MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />El SOIL BORING <br />INJECTION (Air Sparqe, Ozone( <br />OTHER <br />WELL/ SOIL BORING IDs <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />HAMMER/DRIVEN DIA. OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 2 <br />WELL IDs MW4 and MW5 <br />GROUT SPECIFICATIONS Portland Type II (94Ib + 5.5-6 gallons) <br />TREMIE TYPE TO BE USED E AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE <br /> <br />DIAMETER of 8.25 inches to depth of 2) aig feet <br />1:1 PRESSURE GROUT To depth of feet below surface <br />I=1 EXPLOSIVES <br /> <br />From to feet below surface <br />El MUSHROOM CAP <br /> <br />El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />S n aquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br /> <br />Title/Company PROJECT GEOLOGIST / AGE <br />Print Name BRIAN MILL AN Date 11 JULY 2019 <br />Date Issued: I 261 <br />FA Name /I> eliiikat,( 4' 1 r FA Address et.....7-- (e...0444.4-4 FA# 0 0 t $ 5 f0 PR# 0 54-0 oó ; <br />FA PE <br />(75-9- 1 0 <br />WP Reviewed By <br />‘.A) <br />Work Plan Date 1— -/Ira A 9 <br />0 C-57 )5(1C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONNTIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE <br />71/?-47 <br />WELL PERMIT. I INVOICE# <br />WPC 03V1 W I Permit aCt 02 3(3 $152x 2,. 304 zbl 4 1./\] <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />;20.14r orfIgNT USE ONLY <br />(Ativvd keGwv 8/8P9