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)°p, ly r ' �" ° � SA N.J OAQ U I N Environmental Health Department t f Z " ' A J COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 Harlan Road and Louise Avenue City/State/zip Lathrop/CA/95330 Phone N/A Cross Street Lathrop Road, O Street, Bizzbie Street APN N/A Property Owner* City of Lathrop- Public Works Department Phone Address 390 Towne Center Drive City/State/zip Lathrop, CA 95330 C-57 Contractor Gregg Drilling &Testing License# 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-contractor Ahtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 city/state/zip feasant Hill/CA/94523 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air swoe.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ®OVER-BORE DIAMETER of 6 inches to depth of 22.1 feet WELL IDs PZ009, PZ010, PZ011 ❑PRESSURE GROUT To depth of 0 feet below surface GROUT SPECIFICATIONS Cement bentonite grout ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: PZ009 TD 20.1 ft, PZ010 TD 21.1 ft, PZ011 TD 22.1 ft 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. Signed Title/Company Sr.Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG Date August 29, 2018 DEPARTMENT USE ONLY Application Accepted By: � � <= Date Issued: N�( Grout Inspection By/Dates: tC Destruction Inspection By/Dates: t ' Facilit /Site Information FA Name, (;yM , ll�>tfat FA Address 7Uu },I ) FA# Q�. -; PR# 4& 7 FA PE �� 7`',-Ct I -ZAgLI WP Reviewed By L Work Plan Date L�✓ ❑C-57 Q a 57 Authorization for Other to Sign Permit ' orkers Comp ❑Workers Comp Waiver Ww<roachment Permit ❑Access Agreement EKead Agency Approval &KFR COMMENTS/CONDITIONS: (f�,,�G+.�'.-yyr�'t,.y. �2 Nv 5��+�V� �,•hy� 11v� ww c- itiw� 3 -�2�` hn -awt�yC , WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2�l b L 313 $152, 3 4 `j&j b3I7'l� L-)( o ! viyoo5g Sjq 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application