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AN JUAQUIN <br />Environmental Health Department <br />SITE MITIGATION WELL &BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />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 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 7351 W Grant Line Rd city starc F Tracy,CA 95304 Phone 6027144150 <br />Cross Street Chrisman Rd APN 213-07-049 <br />Property Owner* Frank Silva Phone <br />Address 1850 E Grant Line Rd Cop Tracy,CA <br />C-57 Contractor Neil O. Anderson (Terracon) License# 669004 Phone 209-367-3701 <br />Address 902 Industrial Way City/State/Zip <br />ConsultanVSub-Contractor n/a License# n/a <br />Address n/a <br />City/State/Zip <br />Lodi,CA 95240 <br />n/a <br />Phone n/a <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING NUMBER <br />[i hAONITORING ❑ <br />EXTRACTION (VaporlWaler) <br />L) SOIL VAPOR PROBE Ll <br />❑ SOIL BORING <br />❑ INJECTION (Air Sparge, ozone) ❑ <br />LJ OTHER U <br />WELL/ SOIL BORING IDs <br />DESTRUCTION WORT <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS_ <br />TREMIE TYPE TO BE USED <br />COMMENTS: <br />Signed <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX U STOVE PIPE <br />HAMMER/DRIVEN D1A. OF BOREHOLE ❑MULTIPLE CASINGS L7 MULTI-LEVEL WELL CASING DIA <br />hdUD ROTARY CASING THICKNESS TYPE OF CASING: I.) STEEL I .1 PVC [] OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes F] No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: Ll AUGERS n HOSE ❑ PIPE <br />OTHER: GROUT SEAL PUMPED? U Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />AUGERS C-] HOSE ❑PIPE <br />(� OVER -BORE <br />I 1 PRESSURE GROUT <br />❑ EXPLOSIVES <br />MUSHROOM CAP <br />DIAMETER of 6 inches to depth of 2;L, feet <br />To depth of feet below surface <br />From to feet below surface <br />L7 3 feet below surface or feet below surface if >3 feet <br />Ulk <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 �' '. Staff Engineer/Terracon Consultants <br />r1rh,,:,;.;,t;.«: Title/Company <br />Print Name Yuchen Huang Date 4/5/2021 <br />Application Accepted By: _� <br />Grout Inspection By/Dates: �� <br />Destruction Inspection By/Dates: <br />Facilitv/Sifa Infnrmntinn <br />Date Issued: <br />FA Name <br />1868 E. Hazelton Avenue ( Stockton, California 95205 � T 209 468-3420 1 F 209 464-0'13II I www.sjcehd.cotn <br />EHD 29-01 04-01-17 Site Millgatlon Well Permit Application <br />e <br />14,� <br />FA PE <br />WP Reviewed By <br />Work Plan <br />Date <br />`2 <br />` <br />I G57 <br />❑ G57 Authorization for Other to Sign Permit <br />❑Worker's Comp D Worker's Comp Waiver O Encroachment Permit n <br />Access Agreement <br />n Lead Agency Approval MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D <br />BY <br />,D <br />WELL <br />PERMIT# <br />INVOICE# <br />Permit <br />1 P i' <br />:i , <br />$152 x <br />/TE/ <br />4Id <br />Poo <br />2, <br />t' (, <br />_ <br />