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Application Accepted By: <br />Grout Inspection By/Dates: <br />Date Issued: %\, (;# I lig <br />DEPARTMENT USE ONLY <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grows her: <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 11022 Howard Road City/State/Zip Stockton, CA Phone <br /> <br />Cross Street Tracy Blvd APN 189-170-05 <br /> <br />Property Owner Tracy Unified School District Phone 209.830.3245 <br />Address 1875W. Lowell Ave City/State/Zip Tracey, CA 95376 <br />C-57 Contractor Cascade Drilling License# 9 3 8 1 1 0 ph one 9 16 - 638-1169 <br /> <br />Address 3000 Duluth St City/State/Zip West Sacramento, CA <br />Consultant/Sub-Contractor GHD Services, Inc License# Phone 510.420.3303 <br />Address 5900 Hollis St, Suite A City/State/Zip Emeryville, CA 94608 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offslte Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 1=1 HOLLOW STEM BORING DEPTH 20 feet 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 EXTRACTION (VaporMtater) ED HAMMERJDRIVEN DIA OF BOREHOLE 2-inches 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DA <br />0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />EJ SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes El No Boring Da:sing Depth: Casing Die: Ca <br />0 INJECTION (Air Soave, Ozone) 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE rgl PIPE <br />0 OTHER reg OTHER: Direct Push GROUT SEAL PUMPED? 0 Yes gi No (Note: Maximum Freefall Depth a 30 Ft) ' <br />WELU SOIL BORING IDs C;GS-1 through FIGS-4 GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />A WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS <br /> <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface Of feet below surface if >3 feet TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS: 4 borings to collect groundwater samples to approximately 20 feet below ground surface. Depths s <br />subject to change based on field observations. <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Project Geologist, GHD Services, Inc <br />Print Name Nathan Diem Date 10/16/2018 <br />FA Name beA,§7, zsta.o.A._ c_.4A...v i FA Address % \ 0 2,2_ H,t, FA FAA Vigt:ic--Ls---- PRA 0c4.4 I cfil <br />FA PE .)511k.e0 WP Reviewed By L -,I Work Plan Data 94242 141? <br />Agency Approval --mer 0 C-57 riVe:5Aulhorization for Others Sign Permit aio‘ker's Comp 0 Worker's Comp waiver 0 Encroachment Permit 0 Access Agreement Pad <br />COMMENTS/CONDITIONS:6-re o-is" v.) vie"- 6-e-r-k- etAtetP"-k— crAil • <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 1405- 30, $152 x 3 4 col.ii4'7, ! L-V xiti‘ 1 ig 1J-e033%.5118 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />lpho3 .52,1 tax 3 piSZ ?oil 1--si II 112-1 it 5 g_e, 0 11 124, <br />Signed_