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aalvironmental Health DearEment <br />SITE MITIGATION WELL Ot 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 />Adva€1lc� Notic e. ocit.fired For fill Inspe AlOnso �tj b 0 33�N <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 2502 Dorset Lane <br />City/Statep Tracy, CA 95377 <br />Phone Rob Moniz (Arcaas) szsaae-7x77 <br />cress street Blackbird Court APN 238-300-08 <br />Property Owner" Mr. Heredia Phone <br />Address 2502 Dorset Lane City/State/Zip Tracy, CA 95377 <br />C-57 Contract % Penecore ��� �r�� c License# 906899 Phone <br />Address 220 N. East Street City/State/Zip Woodland, CA 95776 <br />Consultant/Sub-Contractor Rob Moniz - Arcadis License# Phone <br />Address 2300 Clayton Rd, Suite 400 _ City/State/Zip Concord CA 94520 <br />(530)661-3600 <br />925.788.7377 <br />CONSTRUCTION WORK TO EtE PERFORMED:'Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION <br />SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 ft ❑BOLTED TRAFFIC BOX ❑ S70VE PIPE <br />❑ EXTRACTION (Vapor/Water) C1HAMMERDRIVEN DIA. OF BOREHOLE 3.5 in ❑ MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA <br />X SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL C1 PVC X OTHER Teflon tubing <br />❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: <br />C14 INJECTION IAsoarae.ozonel HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS C1 HOSE El PIPE <br />C1 OTHER ❑ OTHER: GROUT SEAL PUMPED? [I) <br />Yes ]$( No (Note: Maximum Freefall Depth is 30 Ft <br />WELL! SOIL BORING IDs B-13 GROUT SPECIFICATIONS Hydrated Bentonite Grout 1' to 4'9" in <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 [I HOSE El PIPE <br />COMMENTS: <br />Signed <br />Print Name <br />By: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />rl MUSHROOM CAP ❑ 3 feet below surface or feet below surface if <br />certify that 1 am authorized to complete this <br />San Joaquin County Ordinance Codes and <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />cation and that the work will be done in accord <br />dards; and all other applicable California laws. <br />TitlelCompany e <br />�(� <br />Date Issued: <br />1868 E. Hazelton Avenue 1 Stockton, Ca!iForrtia 95205 I T 209 X138- '? j != 209 404-0135 (yyvwd.sjcehd.com <br />EttD 29-01 08-01-17 Site Mitigation Well Permit Application <br />S Zoog 1 5 w <br />L <br />FA NameDID <br />FA PE <br />-57 <br />C X/ <br />Q <br />❑ C-57 Authorization for Olher to Sign Permit <br />WP Reviewed By <br />❑ Workers Comp EI Workers Comp Waiver ❑ Encroachment Permit ❑ <br />Work Plan Dale <br />Access Agreement Lea <br />El's <br />61✓1 <br />en y ❑ Approval MFR <br />COM EN <br />S/CONDITIONS: <br />u <br />7� <br />S <br />J <br />DATE <br />a WELL PERMIT# <br />vV 0� Q <br />LfiPermit <br />g <br />INVOICE# <br />WP TYPE <br />PE <br />2q6 <br />SC <br />Zj` 3 <br />FEE INFO <br />$152 x <br />AMT REMITTED <br />CHECK# <br />BY 1:111 1 <br />12 <br />1868 E. Hazelton Avenue 1 Stockton, Ca!iForrtia 95205 I T 209 X138- '? j != 209 404-0135 (yyvwd.sjcehd.com <br />EttD 29-01 08-01-17 Site Mitigation Well Permit Application <br />S Zoog 1 5 w <br />L <br />