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Jeff Wong Inspector Environmental Health Department COUNTY Greotness grows here, 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 � 1651; 1 East Grant Line Road Cross Street worth Chrisman Road City/State/Zip Tracy/CA/95304 APN 213-07-041 Property Owner* August Marty and Marilyn Marty 2008 Revocable Trust Address 2517 Summerfield Drive City/State/Zip Stockton, CA 95209 C-57 Contractor Trinity Drillinq, Inc. License# 1010926 Address 114 Fern Street ConsultantJSub-Contractor Citadel EHS - Atten: Scott Grasse, PG Address 1725 Victory Blvd. City/State/Zip Santa Cruz, CA 95060 License# NA City/State/Zip Glendale, CA 91201 Phone NA Phone 209.715.1425 Phone 831.426.5607 Phone 818.246.2702 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING ❑ MONITORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ElEXTRACTION (Vapor/Water) I/ SOIL VAPOR PROBE ElSOILBORING ❑ INJECTION (Air Sparge, Ozone) ❑ OTHER WELD SOIL BORING IDs ❑ HOLLOW STEM BORING DEPTH �30 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 2.25" Geoprobe ElMULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA 3 ElMUD ROTARY CASING THICKNESS TYPE OF CASING: ElSTEEL El PVC ElOTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ElHOSE ElPIPE ❑ OTHER: GROUT SEAL PUMPED? ElYes [INo (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS Temporary 1/4" diameter vapor probes set at 10', 20', and 30' in each soil vapor probe boring with B-1, B-2 and 13-3 hydrated and/or slurry bentonite used as grout and placed at selected depths via tremie pipe, vapor 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 only if site is impacted) # WELLS TO BE DESTROYED 9f OVER -BORE DIAMETER of 2.25" inches to depth of �30 feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED n AUGERS n HOSE n PIPE n MUSHROOM CAP F] 3 feet below surface or feet below surface if >3 feet COMMENTS: v V"6 I` MOL L R� I hereby Signed ��,�t�U lify that I am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Print Name David A. Reinsma, PG Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilitv/Site Information Title/Company President/Trinity Drilling, Inc. Date August 23, 2022 ENT USE ONLY Date Issued: FA Name FA PE �a 0�� WP Reviewed By � � Work Plan Date 8 'L `i' � 2Z C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval FR COM NTS/COpITIONlAs M i roa SV 1. � at(� •b p fQr'J� to Sq,IMP AS wQ 4S -f-1��2'�- Csytk „s �� , -f1� s �C 1�Q i �f�ards 13,14,(6. 4 r?Su` S S �,r2 �/P o� r�� -� �i►6wk� 17 r WP TYPE PE SC FEE INFO AMT REMITTED CHHECK# RECV''D� DATE INVOICE# Permit $14X ` ` Q� �BY �/1i ��Z✓ OL A �WELL'PELRMIT#Q� V O0 `T D q C6n-F' i r� �-fi�- �r I� �a � g� . 1868 E. Hazelton Avenue � Stockton, California 95205 QT 209 468-3420 � F 209 464-0138 1 wvvw.s�cehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application 7 2