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SAN JOAQUIN C 0 U N -- Environmental Health Department 011 C MITIOATIUM VV'ELL &BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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 2502 Dorset Lane City/State/Zip Tracy, CA 95377 Phone RobMonz(Arcadis)925-788-7377 cross street Blackbird r% w4 APN 238-300-08 Property Ownet" Mr. and Mrs. Fisher Phone Address 2502 Dorset Lane City/State/Zip Tracy, CA 95377 C-57 Contractor TSA Drilling / Penecore License# 906899(530) Phone Address 220 N. East Street City/State/Zip Woodland, CA 95776 Cons ultandsub-Contractor Rob Moniz - Arcadis License# Phone Address 2300 Clayton Rd Suite 400 City /State/Zip Concord CA 94520 661-3600 925.788.7377 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 8 R ❑ BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION (VaporMater) ❑ HAMMER/DRIVEN 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 D4 OTHER Teflon tubing ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes X No Boring Dla: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge. ozone) HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: []AUGERS ❑HOSE []PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes j$(No (Note: Maximum Freefall Depth is a0 Ft) WELU SOIL BORING IDs B-14, B-15 GROUTSPECIFICATIONS Hydrated Bentonite Grout 1' to 4'9" in DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: rcfiEcl<ALLTFiATAPPLY� #WELLS TO BE DESTROYED ❑OVER -BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 33 feet below surface or feet below surface if>3 feet COMMENTS: e4(ws f �-LV1�--��jyVl 01 QIC l rI"a k I ate.' � /,�r" e+ , tL AA :3 � r , it I S 11�o r� 1 -f j � ro -0-tA o -y\ r� C o rdr , tom" I that I b Joaquin Signed Print N. Application Accepted By: _ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name �y uthorized to complete Title/Compa(�ny {�(i I Date "►' I this application and tha unty Ordinance Codes and Standards, and all ' 2a be done in accordance le California laws. Issued: 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-34� F 209 464-0138 1 vvvvw.sjcehd.com EHD 29-07 08-01-17 � rte Mitigation YVell Permit Application -.�,_ FA PE ❑ ZC1 w C-57 ❑ G57 Authorization for Other to Sign Permit WP Reviewed By ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Work Plan Date ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS: i'r0.Cc'G 5 CIOWN �N noke�=WT L{ d� �✓ljk I c �7 �6-�G �� Z. b !14L G V+ 4� t 2. WP TYPE PE SC 230 ` 313 FEE INFO $152x AMT REMITTED CHECK# REC% D BY �l DATE �' L PERM[ T# �A/P co INVOICE# Permit 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-34� F 209 464-0138 1 vvvvw.sjcehd.com EHD 29-07 08-01-17 � rte Mitigation YVell Permit Application