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SAN JUAQUIN <br />Environmental Health Department <br />SITE MITIGATION ViIELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERA4IT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described, <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1'115.3, and the San Joaquin County Well Standards. <br />Job Address Grant Line Rd <br />Rd <br />Cross Street Chrisman <br />CitylState/Zip Tracy,CA 95304 <br />APN 213-07-085 <br />Phone 6027144150 <br />Property Owner Frank Silva Phone <br />Address 1850 E Grant Line Rd City/State/Zip Tracy,CA <br />C47 Contractor Neil O. Anderson (Terracon) License# 669 Phone <br />Address 902 Industrial Wa City/State/Zip LodiCA 95240 <br />Consultant/Sub-Contractor n/a <br />Address n/a <br />209 <br />-367-3701 <br />, <br />License# n/a Phone n/a <br />City/State/Zip n/a <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WELU80RING NUMBER <br />❑ MONITORING L_l <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />ElEXTRACTION (Vapor/Water) ❑ <br />[ISOIL VAPOR PROBE L..1 <br />CJ SOIL BORING ❑ <br />❑ INJECTION (Air Sparge, Ozone) ❑ <br />❑ OTHER <br />WELL/ SOIL BORING IDs <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS_ <br />TREMIE TYPE TO BE USED <br />COMMENTS: <br />Signed <br />HOLLOW STEM BORING DEPTH U BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMER/DRNEN DIA. OF BOREHOLE ❑ h1ULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: [.] STEEL ❑ PVC (] OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes F1 No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS O HOSE O PIPE <br />OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 FI) <br />GROUT SPECIFICATIONS <br />AUGERS ❑HOSE (]PIPE <br />[�� OVER -BORE <br />(.; PRESSURE GROUT <br />EXPLOSIVES <br />From <br />MUSHROOM CAP <br />DIAMETER of � inches to depth of � feet <br />To depth of feet below surface <br />to feel below surface <br />Ll <br />3 feet below surface or feet below surface if >3 feet <br />C <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Huang, Yuchen :: ....r1I1 it 11t •1 ,otU i� tr- CC . Title/Company Staff Engineer/Terracon Consultants <br />Cra Li <br />Print Name Yuchen Huang Date 4/5/2021 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />FA Name <br />1868 E. Hazelton venue I Stoc ton, California 9520 5 J T 209 46II�3�120 1 P 209 464-0138 1 www.sjcehd.com <br />EHD 29.01 08.01-17 Cr�/� L�'— Site Mitigation WellPermit Application <br />C �'� � <br />� Cj <br />10 <br />FA PES <br />WP Reviewed By <br />Work Plan Date <br />( f46 ITowo#oo I <br />Gl C-57 ❑ C-57 Authorization for Other to Sign Permit <br />❑ Worker's Comp ❑ Workers Comp Waiver n Encroachment Permit <br />Fol Access Agreement ❑ <br />Lead Agency Approval FR <br />COMM NTS/CONDITIONS: <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTEDI <br />CHECK# <br />I RECV'D BY <br />IDATE <br />I <br />INVOICE# <br />Permit <br />$152x t <br />"I t`°' <br />J <br />`7 (j <br />t /" ,/WELL,>PERMIT# <br />�0V <br />q03 <br />