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SQ N<J OAQ U I N Environmental Health Department COUNTY— .' _ hfP:7/fl t's5 grows her,- 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. ,/ ate" Z 7 Z3 C'P'A ,bC..'," Job Address 100 ft south of Cedarbrook Way and Brookfield Ave City/State/ZIP Lathrop,CAA 9,533g Phone N/A Cross Street Cedarbrook Way and Brookfield Ave APN N/A I", 02 q' Property Owner* City of Lathrop-Public Works Department Phone Address 390 Towne Center Drive City/State/ZIP Lathrop,CA 95330 C-57 Contractor Yellow Jacket Drilling License# C57-1034407 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State/Zip Rancho Cucamonoa.CA 91730-5743 Consultant/Sub-Contractor Ahtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd,Ste 312 Cfty/State/Zip Pleasant Hill,CA 94523 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wetls Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 145 ft bgs ■BOLTED TRAFFIC BOX ❑STOVE PIPE ® EXTRACTION(Vapor/Water) 1 ❑ HAMMER/DRIVEN DIA OF BOREHOLE 16 in ■MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ! MUD ROTARY CASING THICKNESS SCh 80-1.06in TYPE OF CASING: e STEEL p PVC ❑ OTHER steel screen,PVC blank ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes©No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Ar saxes.ozoml ❑ HAND AUGER GROUT SEAL DEPTH 119-122 ft bgs TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? E Yes❑No (Noce:Maximum Freelall Depth is 30 Ft) WELUSOIL BORINGIDs EWCCS GROUT SPECIFICATIONS Type II Portland cement w/albs of powdered non-beneficiated bentonite w/7 gal water per 94-Ib sack of cement, mechanically mixed DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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: I hereby ce hat I am authorized to complete this application and that the work will be done In accordance with --SanAaqtYn Cou r mance Codes and Standards,and all other applicable California laws. Signed "s <!_< t�. Title/Company Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr Date July 12,2019 DEPARTMENT USE ONLY /� 4 Application Accepted By 1A Daft hued: Grout Inspection By/Dates: - Destruction Inspection BylDates: O FacIIItv1S11It Information �(j^�f�ii ��,, ��L� n fr FA Name r i ti )1/IG FA Address :TOO F 06 a C 3 � FA PE9� WP Reviewed By Work Plan Date ❑G57 Q G57 Authodtation for Dow to Sign Permit ❑Worker's Comp ❑Wakefs Camp W*w ❑Encroachment Permit ❑Aocrss Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: ;:Pk'rw Peru Iy ta.a;f q1 4,11if I AWit;.'CLS gpry by .i n*r t f o f 3/t pts[ _I WP TYPE I PE Sc T FEE INFO AMT REmirrEDI CHECK#I RECV'D BY DATE I WELL PERMIT# I INVOICE# Permit $152 x N 0 C S Y 5 C 1868 E. Hazelton Avenue I Stockton, California 9520i5'1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 09-01.17 3-1 ?4t- Site Mitigation Well Permit Application R/o v,