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t .- SAN JOAQUIN COUNTY rqttp Greatness grows here. Environmental Health Department SITE MITIGATION WELL ot 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 1681 East Grant Line Road Cross Street North Macarthur Drive City/State/Zip APN 21307039 Tracy, CA 95304 Property Owner* Marilyn Marty, Trustee of the August Marty and Marilyn Marty 2008 Revocable Trust Address 1681 East Grant Line Road City/State/Zip Tracy, CA 95304 C-57 Contractor PeneCore Drilling Li # 906899 Address 220 N East Street Consultant/Sub-Contractor Ramboll US Consulting, Inc. Address 2200 Powell Street, Suite 700 cense License# N/A City/State/Zip , CA 95776 Woodland Emeryville City/State/Zip , CA 94608 Phone N/A Phone 209-513-1078 Phone 530-661-3600 Phone 510-420-2546 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 20.5 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ElEXTRACTION (Vapor/Water) �i HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 inches El MULTIPLE CASINGS ElMULTI-LEVEL WELL CASING DIA X SOIL VAPOR PROBE 3 ElMUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ElSTEEL ElPVC 171OTHER El SOILBORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ElYes I$( No Boring Dia: Casing Dia: Casing Depth: ElINJECTION (Air Sparge, Ozone) ElHAND AUGER GROUT SEAL DEPTH 0 to 4 feet bgs TREMIE TYPE TO BE USED: ❑ AUGERS ElHOSE ElPIPE ❑ OTHER ElOTHER: GROUT SEAL PUMPED? ElYes X No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs SG -N-75, SG -E-25, SG -E-75 GROUT SPECIFICATIONS Neat portland cement and/or hydrated bentonite crumbles n I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ®OVER -BORE DIAMETER of 3.25 inches to depth of 20.5 feet WELL IDs SG -N-75, SG -E-25, SG -E-75 F1PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat cement grout (Portland, Type II) ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [:1AUGERS ❑ HOSE ❑ PIPE ElMUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: Soil vapor probes will be multi -depth with probe tips installed at 5, 10 and 20 feet bgs in the same boring. Soil vapor probes will be installed using direct -push technologies (DPT) drill equipment. Vapor wells will remain installed for approximately 1-2 weeks prior to abandonment. Signed I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company Senior Consultant, Geologist / Ramboll US Consulting, Inc. Print Name Tommy Winger Date 3/3/2022 DEPARTMENT USE ONLY Application Accepted By:tlw� Date Issued: ��67 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name �4 �) I FA PE � WP Reviewed By Work Plan Date 3 /3 Z � Z2 ElC-57 S47 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ElEncroachment Permit Access Agreement ❑ Lead Agency Approval MFR COMMENTS/CONDITIONS: Ci� OY�SN �So S{ --1s WP TYPE PE SC I FEE INFO AMT REMITTED CHECCK# RECV'D, dBJY DATE WELL PERMIT# INVOICE# Permit e5 3 � $152 x Zgw 'v/ 21q1?,, I v1% Foo L ion. -Fl Ir�4 -en. rI � � C � � 1868 E. Hazelton Avenue � Stockton, California 95 5� T 09 468-34201 F 209464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application ion. -Fl Ir�4 -en. rI � � C � � 1868 E. Hazelton Avenue � Stockton, California 95 5� T 09 468-34201 F 209464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application