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SAN JOAQUIN CCNU NTY Greatness grows here. 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 1681 East Grant Line Road Cross Street North Macarthur Drive Property Owner* City/State/Zip APN 21307017 Tracy, CA 95304 Marilyn Marty, Trustee of the August Marty and Marilyn Marty 2008 Revocable Trust Address 1681 East Grant Line Road C-57 Contractor CSTracyCA 95304 PeneCore Drilling Address 220 N East Street Consultant/Sub-Contractor Ramboll US Consulting, Inc. Address 2200 Powell Street, Suite 700 ity/tate/Zip , License# 906899 Phone N/A Phone 209-513-1078 Phone 530-661-3600 City/State/Zip Woodland, CA 95776 License# N/A Phone 510-420-2546 City/State/Zip Emery ville, CA 94608 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 El EXTRACTION (Vapor/Water) �i HAMMER/DRIVEN DIA. OF BOREHOLE 2.25 Inches [j MULTIPLE CASINGS El MULTI-LEVELWELL CASING DIA X SOIL VAPOR PROBE 5 El MUD ROTARY CASING THICKNESS NIA TYPE OF CASING: El STEEL El PVC ❑ OTHER ❑ SOIL BORING El PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: El INJECTION (Air sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 0 to 4 feet bgs TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE ❑ OTHER El OTHER: GROUT SEAL PUMPED? I.] Yes No (Note: Maximum Freefall Depth is 30 Ft) WELL] SOIL BORING IDs SG -N-25, SG -S-25, SG -S-75, SG -W-25, GROUT SPECIFICATIONS Neat portland cement and/or hydrated bentonite crumbles SG -W-75 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 5 ®OVER -BORE DIAMETER of 3.25 inches to depth of 20.5 feet WELL IDs SG -N-25, SG -S-25 SG -S-75, SG -W-25, SG -W-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 [:1 AUGERS ❑ HOSE ❑ PIPE El MUSHROOM 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 Print Name 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. Tommy Winger Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Fnr_ility/Sita Infnrmitinn Date 3/3/2022 Date Issued: �� ` l Z0 �� FA Name li /i� FA# FA PE �� 5"Q WP Reviewed By �� Work Plan Date � �� O20 Z ❑ C-57 Vn 57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Pomp Waiver croachmenttPPermit ❑ Access Agreement ❑ Lead Agency Approval JVWFR COMMENTS/CONDITIONS: K OY res U, S atop r1 `7 r 5�� f f10001 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT#�j INVOICE# Permit � 3 (3 1$152 x '�� / � 7�Z Of 00 1 1868 E. Hazelton Avenue � Stocktonll ornla 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application