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I hereby certify thatl 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 STAFF GEOLOGIST / AGE <br />Date 1/17/19 1 Ren M. Toth <br />Signed <br />Print Name <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />DEPART ENT USE ONLY <br />2.-/ <br />SAUOAQUIN Environmental Health Department (gibi COUNTY <br />odS:Lia; <br />\—<±pRoax•,./ Greatness grows here. <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 1151 Holly Drive City/State/Zip Tracy, California 95304 Phone (209) 467-1006 <br />Cross Street East 11th Street APN 233-120-15 <br />Phone (209) 467-1006 Property Owner* Denzel Thompson <br />Address 1 West 12th Street city/state/Zip Tracy, California <br />(209) 467-1006 C-57 Contractor Slagle Drilling Corporation License# 1046151 Phone <br />Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA <br />(209) 467-1006 Consultant/Sub-Contractor AGE License# 680227 Phone <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: "Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />EI MONITORING •f_34. HOLLOW STEM BORING DEPTH 20' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 8.25" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: l: STEEL El PVC 0 OTHER <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes EJ No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION (Air Spam, Ozone( C-ra.- HAND AUGER GROUT SEAL DEPTH 1.5' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes El No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs MW-6 GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See attached Work Plan and site plan ** <br />FA Name Leva,4 15. ivf 6u <br />n5 <br />FA Address 3 gas4 ( 1 ii, ft.. FA 00 23cieri PR# USW /XV/ ex) <br />FA PE 2A (/0 WP Reviewed By L, --A/ Work Plan Date gizo (vat-; <br />0 C-57 -Ele57 Authorization for Other to Sign Permit Er‘keris Comp 0 Worker's Comp Waiver 0 Encroachment Permit a '‘ess Agreement aread Agency Approval LI f R <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit vid t 31, $152x 1 kt t52- 1)04- L qtA f Vi kis P to 31v4,0 <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