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.; ti SAN JOAQUIN 1, COUNTY Greatness grows here, Jeff Wong Inspector Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 Cross Street nd 11781 East Grant Line Road North Chrisman City/State/Zip Tracy/CA/95304 AP N 213-07-9 Property Owner* August Marty and Marilyn Marty 2008 Revocable Trust Address 2517 Summerfield Drive C-57 Contractor Trinity Drilling, Inc. Address 114 Fern Stre ConsultantJSub-Contractor Citadel EHS - Atten: Scott Grasse, PG Address 1725 Victory Blvd. City/State/Zip Stockton, CA 95209 License# 1010926 Phone NA Phone 209.715.1425 Phone 831.426.5607 City/State/Zip Santa Cruz, CA 95060 License# NA Phone 818.246.2702 City/State/Zip Glendale, CA 91201 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH -30 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2.25" Geoprobe ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA E/ SOIL VAPOR PROBE 4❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: 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 ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs B-7, B-8, B-9 and B-10 GROUT SPECIFICATIONS Temporary 1/4" diameter vapor probes set at 10', 20', and 30' in each soil vapor probe boring with hydrated and/or slurry bentonite used as grout and placed at selected depths via tremie pipe, vapor #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑ AUGERS El HOSE [I PIPE El COMMENTS: � irtAr4 ye MQ y Q r� Signed I hereby probe tubing pulled after sampling for each location and bore hole capped with Portland cement. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) (over -bore onlif site is impacted) y OVER -BORE DIAMETER of 225" inches to depth of �30 feet ❑ PRESSURE GROUT To depth of feet below surface El From to feet below surface (/ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet 11, 11111 (that I am authorized to complete this application and that the work will be done in accordance with Jciaquin County Ordinance Codes and Standards, and all other applicable California laws. Print Name David A. Reinsma, PG Application Accepted By: Grout Inspection By/Dates: USE ONLY Destruction Inspection By/Dates: Facilitv/Site Information Title/Company President/Trinity Drilling, Inc. Date August 23, 2022 1 1111 ARTMENT Date Isst FA Name 1868 E. Hazelton Avenue � Stockton, California 95205 � T 20946M420 v,• l FA PE WP Reviewed By �(�,, Work Plan Date 2 � 2 C-57 ElC-57Authorization for Other to Sign Permit ❑ Worker's Comp ElWorker's Comp Waiver ElEncroachment Permit ElAccess Agreement ❑ Lead Agency Approval MFR COMMENTS/ ONDITIONS: rZ r,^ if -4w' /� I A S k -P i Nab- �roq+OL o�-�r V tom. I rr S ` +kQQ,Pvie �� ct We 6"�f �.w� �,a G,ter a u is o v WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# PermitZqo 301 $15 3 I Z 1::50 v ILY Z 0 6 EHD 29-01 04-04-07�r' � A � � �, p �,1- �� �S it F 209464-0138 1 vvww.sjcehd.com Site Mitigation Well Permit Application