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Job Address <br />Cross Street <br />604 and 606 West 11th Street City/State/Zip Tracy, CA 95376 <br />Roosevelt Avenue APN 2' <br />Property Owner* <br />1314 Walnut <br /> <br />Cula Davanis Trust (Sunday Borges-Trustee) °I-D. —0-1- <br /> City/State/Zip Tracy, CA 95376 <br />C-57 Contractor Environmental Control Associates <br />License# 695970 <br />Phone ( IA) S GL( <br />Phone (831) 662-8178 <br />City/State/Zip Oakland, CA 94606 Address 1017 22nd Avenue, Suite 107 <br />5 <br />NUMBER INSTALLATION TYPE <br />CI HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />5 borings to 15 feet bgs using Geoprobe direct push rig COMMENTS: <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />RECEIVED <br />SAN JOAQUIN COUNTY <br />JUL 07 7 2017 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL H <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicePcilKSERw' <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 />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 />Phone (209) 835-7896 <br />Address <br />Address 3011 Twin Palms Drive city/state/zip Aptos, CA 95003 <br />Consultant/Sub-Contractor Partner Engineering and Sciencq_icense# Phone (510) 323-4499 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />CI MONITORING <br />DI EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparge Ozone) <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 15' <br />DIA. OF BOREHOLE 2.25" <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes D No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes No <br />GROUT SPECIFICATIONS <br />OTHER El OTHER: <br />WELL/ SOIL BORING IDs B1 through B5 <br />D BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING El STEEL El PVC 0 OTHER <br />Boring Di a: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: DI AUGERS 0 HOSE XI PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED U AUGERS ID HOSE U PIPE <br />D OVER-BORE <br />PRESSURE GROUT <br />EXPLOSIVES <br />D MUSHROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />12 3 feet below surface or feet below surface if >3 feet <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />un - County Ordinance Codes and Standards, and all other applicable California laws. <br />_ Signed Title/CompanStaff Scientist/Partner Engineering and Science <br />Print Name Brett Bova Date June 30, 2017 <br />DEPARTMENT USE ONLY <br />FA Name FA Address FA # PR# <br />FA PE WP Reviewed By Work Plan Date <br />D C-57 0 C-57 Authorization for Other to Sign Permit CI Workers Comp CI Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan <br />Permit $130 x