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p ''° SAN:JOAQUIN Environmental Health Department 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 Louise Avenue City/State/zip Lathrop/CA/95330 Phone N/A Cross street 5th 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 Pleasant 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 Sparge.Ozone) ❑ 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 2 ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs PZ012 and PZ013 ®PRESSURE GROUT To depth of 3 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: PZ012 TD 26.1 ft, PZ013 TD 29.1 ft; proximity of utilities prevents over drilling 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 PARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name 5'k--Ip Oil FA Address W� c fi, (2{ FA# C0,L,,1 S�_3 PR# CSN4 Z,-7_5- FA PE Z-9 •�m, WP Reviewed By Work Plan Date Lei x-'11 ❑C-57 -57 Authorization for Other to Sign Permitori er's Comp ❑Workers Comp Waiver LKIcroachment Permit ❑Access Agreement [j ead Agency Approval FR COMMENTS/CONDITIONS:(�f t,, w , ,-,.Ali ji, -jr— 5--A w--v-kr-v-\ WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECv'D BY DATE WELL PERMIT# INVOICE# Permit 7.,Cb0 Z 313 $152 x 2 3 Gy - 0'r76'SY L- 7/",jig tJ C0C; SD5 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