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i # JU OWN nvironmental Healll Depari.ment SITE MITIGATION WELL &BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT A EXPIREt1 YEAR FROM DAAAAAA TE ISSUED / / �y ^O �� I ollr<_ kik an%..o N€3tice I`vehis � F}a• All ItI �t�e; tlf�T�S 48 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 2532 Dorset Lane City/Statep , TracyCA 95377 Moniz (Arcadis925•'188-7377 phone cross streec Blackbird Court APN 238-300-05 Property Owner' Mr. and Mrs. Fisher Phone Address 2532 Dorset Lane A r City/State/Zip Tracy, CA 95377 C-57 Contra rAL Peneeore � ./ �' ]! r i Iho� License# 906899 Phone Address 220 N. East Street City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor Rob Moniz - Arcadis License# Phone Address 2300 Clayton Rd Suite 400 City/State/Zip Concord CA 94520 Rob ) (530} 661-3600 925.788.7377 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft ❑BOLTED TRAFFIC 80X ❑STOVE PIPE ❑ EXTRACTION (VaporiWater) ❑ HAMMERDRIVEN DIA. OF BOREHOLE 3.5 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE ��❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC X OTHER Teflon tubing ❑ SOIL BORING O PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes A No Boring Dia: Casing Ola: Casing Depth: ❑ INJECTION (Ar Spmqet Ozw HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes XNo (Note: Maximum Freefall Depth Is 30 Ft) WELD SOIL BORING IDs B-12 GROUT SPECIFICATIONS Hydrated Bentonite Grout V to 4'9" in DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE OMMENTS: DESTRUCTION � .�}�—I `� 1 FA Address FA# METHOD: PR# FA Name fCHECKALLTHATAPPLY) WP Reviewed By ✓� ❑ Worker's Comp ❑ Worker's Camp Waiver ❑ Encroachment Permit Work Plan Date l �g ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS /_ 114 1 l 1 iV\w i ❑OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface MUSHROOM CAP INVOICE# 1713 feet below surface or feet below surface if >3 $152 x ❑ t hereby certi that I am authorized to complete this application and that the work will be done in accordance with Joaquin County Ordinance Codes and Standards, and all other applicable California laws. . Signed Title/Companyl) Print Name t/ Date /a? to 'i ARTMENT USE ONLY Application Accepte By: Date Issued: Zoo 20/5? Grout Inspection By/Dates: oeerl - %ru P7Z Destruction Inspection BylDates: 1868 E. I-4azelton Avenue ( Stockton. California 95205 J 'r 209 44168•-3420 { r 209 404-0-133 { thAntw.sjcehd.com EHO 29-01 08-0t-17 /^ Site MiGg@non W P it Application 2 � .�}�—I `� 1 FA Address FA# PR# FA Name FA PE Z9 -57 ❑ C-57 Authorization for Other to Sign Permit WP Reviewed By ✓� ❑ Worker's Comp ❑ Worker's Camp Waiver ❑ Encroachment Permit Work Plan Date l �g ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS /_ 114 1 l 1 iV\w i WP TYPE PE SC FEE INFO AMT REMITTEDI CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# Permit O 3 $152 x dsLl C C,Ivif Do to 1868 E. I-4azelton Avenue ( Stockton. California 95205 J 'r 209 44168•-3420 { r 209 404-0-133 { thAntw.sjcehd.com EHO 29-01 08-0t-17 /^ Site MiGg@non W P it Application 2