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For Wells and Borings Used for Contaminant Investigations and Remedi <br />SITE MITIGATION WELL & BORING PERMIT APPLI <br />t€04, <br />SAN.J0Miri <br />COUNTY— <br />Greatnecs wows heft 414# eiV10 <br />IfV(41# 2041 <br />Environmen .1 Healtkpepartment <br />Otto <br />Cross Street S. PARADISE AVENUE 213-170-27 APN <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 6599 AND 6735 W. GRANT LINE ROAD City/State/Zip TRACY, CA Phone <br /> <br />Property Owner* <br />Address <br /> <br />C-57 Contractor <br />Address <br /> <br />TRACY ALLIANCE GROUP LLC <br /> <br />BILL ABOUMRAD 510-744-3530 <br />Phone YUCEL CELEBI 510-673-5932 <br /> <br />41111 MISSION BOULEVARD City/State/Zip <br />License# <br />FREMONT, CA 94539 <br /> <br />TERRACON CONSULTANTS INC 669004 <br /> <br />209-367-3701 Phone <br /> <br />902 INDUSTRIAL WAY <br /> <br />City/State/Zip LODI CA 95240 <br /> <br />Consultant/Sub-Contractor WOODWARD DRILLING License# 710079 Phone 707-374-4300 <br />Address PO BOX 336 City/State/Zip RIO VISTA CA 94571 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING <br />MONITORING <br />EXTRACTION (VaporNVater) <br />SOIL VAPOR PROBE <br />421—SOIL BORING <br />INJECTION (Air Spam. Ozone) <br />1:1 OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 HOLLOW STEM BORING DEPTH 2 ft - 10 ft <br />HAMMER/DRIVEN DIA. OF BOREHOLE 4 in - 6 in <br />MUD ROTARY CASING THICKNESS <br />21 2- PUSH POINT (GP/ CPT) CONDUCTOR CASING <br />...a HAND AUGER GROUT SEAL DEPTH <br />OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br /> GROUT SPECIFICATIONS NEAT CEMENT TO SURFACE <br />BOLTED TRAFFIC BOX U STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: U STEEL 0 PVC 0 OTHER <br />D Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE U PIPE <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS 0 HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 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 />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br /> ' ( Title/Company TERRACON CONSULTANTS INC <br />Print Name TAMARA K WOODS Date MARCH 20, 2019 <br />Application Accepted By: <br />Grout Inspection By/Dates: ..egsear.,,Ar.-1 <br /> DEPARTSENT USE ONLY <br />Date Issued: q <br />44- 4 <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name ,j (64)4 g. cate, FA Address (.61(1.---4 4°13T 0 • (rnr.e <br />1„.“,„4- A-4 _ _ <br />FA# 00 VS-i e 3 PR# Ds-4 43 ,04 <br />FA PE SO WP Reviewed By <br />L <br />Work Plan Date 3 itze_)e_7I. [1 <br />0 C-57 C-57 Authorization for Other to Sign Permit EKNorkers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval IDIVI(R <br />COMMENTS/CONDITIONS: 1"./44-erktv '''s Gke,A V-Lik V-tra)44- 5L1\ 6e-, CA44"def' ) Co vvif"."'ve•A lt-</ 0-.-4-1 ckLies4.- oc v-be-..--vi • <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 7,05 -3 t . $152x _3 (k %la 22 E04)3 I- -Az 4t IS I 1,ci it,-Irar3qS0 I <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 />rf "7"03 S23 4 152, X3 4 451, 7d3 " -3( ) L s(2120