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DESTRUCTION WORK TO BE PERFORMED:,/,,,.1 .1111111111111.111461 --- ,...... _ ,HOD: /CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED None, semi-permanent r 9 OVER-Be -- <br />WELL IDs SG-5,SG-11,SG-12 010' GW-1040' )11%..1. <br />..„ r <br />SURE GROUT <br />GROUT SPECIFICATIONS ile-a-1" Cevvve4A-31--- ery-tAti D EXPLOSIVES <br />TREMIE TYPE TO BE USED CI AUGERS 0 HOSE FIPIPE i 0 MUSHROOM CAP <br />COMMENTS: <br />3 soil gas wells all at 10 feet, 1 grab groundwater boring at 40 feet <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />3 feet below surface or feet below surface if >3 feet <br />c..rj lity c. <br /> Q SAN JOAQUIN <br />L'aitild' COUNTY <br />,fiSzeir <br />GrPritt-H,ss <br />Environmental Health Department <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 />Central Parkway Mountain House, CA 95391 925-239-6932 Job Address City/State/Zip Phone <br />Cross Street N/A APN 209-06-048 <br />Property Owner. Century Communities - Jeff Inabnit Phone <br /> 925-239-6932 <br />Address 4701 Sisk Road, Suite 103 City/State/Zip Modesto, CA 95356 <br /> <br />PeneCore Drilling, Inc 906899 530-661-3600 C-57 Contractor License# Phone <br />220 N East St Woodland, CA 95776 Address City/State/Zip <br />Consultant/Sub-Contractor <br /> ENGEO - Shawn Munger License# CA CHG #413 <br />Phone 916-580-6535 <br />Address 2213 Plaza Drive City/State/Zip Rocklin, CA 95765 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />1:1 MONITORING <br />0 EXTRACTION (Vapor/Water) <br />61 SOIL VAPOR PROBE <br />El SOIL BORING <br />o INJECTION (Alr Spam, Ozone) <br />ID OTHER <br />WELL/SOIL BORING IDs <br /> <br />NUMBER <br />3 <br /> NI <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 3010' . 10 40' 0 BOLTED TRAFFIC BOX ID STOVE PIPE <br />D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL ID PVC D OTHER <br /> <br />DIA. OF BOREHOLE 4^ <br /> <br />CASING THICKNESS None <br />CONDUCTOR CASING ID Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br /> <br />Boring Dia: Casing Dia: Casing Depth: <br /> <br />TREMIE TYPE TO BE USED: 0 AUGERS D HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />5G-1,SG-2,SG-3 010' GW-1040' <br /> <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 />Signed <br /> Title/Company Staff Engineer/ ENGEO <br />Print Name_ Kofi Bonner Date 1/08/2019 <br />DEPARTMENT USE ONLY <br />"A\A{ .rT—MVA/JtAOAV <br />561 cit-SC-(19.vje cetov4437 40 p-ouir <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address 2:333 s 0,10,4, (.4 , 044,44 FA# i.7,60., ( gm, ' '76 79841 Li <br />FA PE WP Reviewed By vr Work Plan Date I /4 iq <br />ti) C-57 0C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />ft'W— (7 ll--'bS Oplq <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# ,...-1 INVOICE# <br />Permit ,0 05- 313 $152 x 3 Lislo,x) (do PO 039 I 1 1 /A103)76;4 <br />1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br /> <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br /> <br />111°/11 S.SAYS Vaal SgeirD 71 9__q 0-3 (.(,(-Q,e.ita,) <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Date Issued: 26 a <br />1(31 545 -z, 66.11,s6a <br />ItA4101 14154411ei 1/(°114 Cria