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S A AUU1 q <br />N!1] U 4 V <br />f . ` C fir! L l`%ki y t._ .. <br />fr <br />Me grows <br />will <br />it 161F071ar ental Health <br />SITE MITIGA u OUN WML <br />For Wells and Borings Us,0c1 u0r Cont��alom tl Investigations and Rernedia"dolon <br />NON-REFUNDABLE pERMIi Ei(�l{�ES 1 YEAR SROM D,'1TE ISSUkU <br />Q Hoag° vance tr ice Reall Uiii O[1 F(oufa 61 @ Ofill 0 C bona <br />Application is hereby made to San Joaquin County for a permik 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 />Joh Address 4707 PACIFIC AVENUE <br />Cross Street <br />MARCH LANE <br />Property Owner* <br />Address <br />TARGET CORP ALTUS GROUP USA INC. 0313 <br />PO BOX 72028 <br />C-�7 Contractor PENECORE <br />Address <br />220 N. EAST STREET <br />ConsultantlSub-ContractorTERRACON CONSULTANTS <br />Address 902 INDUSTRIAL <br />WAY <br />CitylStatelZlp STOGKTON, GA Ph©ne NIA <br />c�PN 101-160-04 <br />Phone <br />/State/Zip PHOENIX ! AZ / 85050 <br />License# 906899 Phone 530-661-3600 <br />City/State/Zip WOODLAND CA 95776 <br />License# 669004 Phone 209-367-3701 <br />CitylState2ip LODI, CA 95240 <br />TYPE 0{= WELLI>30RING <br />❑ t4tONITORING <br />❑ <br />EXl'13ACTI01`l (Vaporl4Vater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />❑ INJECTION (Air Sparge ozone) <br />® OTHER <br />WELD SOIL BORING IDs _ <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />_ li HOLLOW STEM BORING DEPTH < 1(f F T F3GS ❑BOLTED TRAFFIC BOX ©STOVE PIPE <br />❑ <br />fl HAMMER/DRIVEN DIA, OF BOREHOLE _ MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA <br />3 ("I MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />Ig PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />1-1 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: []AUGERS ❑HOSE %PIPE <br />OTHER: GROUT SEAL PUMPED? gYes []No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />®ESTRUCTI®IV W®RK T® �E PEREORME®: DESTRUCTIOi�! ItflETtiOD: (CHECK ALL THAT APPLY) <br />WELLS TO BE DESTROYED � OVER -BORE DIAMETER of inches to depth of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of.. feet below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From . to feet below surface <br />TDMAir TVpI= Tn RF I IRFn n AI IrFmRS I-1 HOSE M PIPE EIMUSHROOM CAP El3 feet below surface or feet below surface it <br />ENTS: Meat Gement to surface <br />1;:� Cet�nty <br />Signed <br />Print Narne TONY MIS CiCF <br />Applica#ion Accepted By: \IVOL <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />I�i� �#s�iiaati;t� �rrd fiat #E�e work w� �e done iri �c�trrdal <br />-and 3i�rrdatrda, and ail �ther.appiilcatrie �$iltoraia_�rws. <br />Title/Company TERRACON CONSULTANTS INC. <br />nate JUNE 17, 2020 revised October 22, 2020 <br />���� �. Hazelton Avenue � Stockfon, C�lifarni� 95208 � `f 209 468-3420 { F 209 464�0'I38 � www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitlgatlon Welt PennitApprration <br />