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p rN <br /> 40, <br /> S A N.,J Q A Q U I N Environmental Health Department <br /> -COUNTY-Greatness grows here, <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 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 Sharpe Army Depot, 700 Roth Road city/staterzip Lathrop,CA 95330 phone N/A <br /> Cross Street N/A APN 198-020-01 <br /> Property Owner` U.S. Department of the Army Phone 831-242.4132 <br /> Address U.S.Army Garrison Presidio of Monterey Directorate of PLb iC Works,P.O.Box 5004 City/State/Zip Monterey, CA 93944 <br /> C-57 contractor Yellow Jacket Drilling License#` C57-1034407 phone 909-989-8563 <br /> Address 9460 Lucas Ranch Road city/staterup Rancho Cucamonga,CA 9 <br /> ConsultanUSub-contractorAhtna Environmental, Inc. License# N/A Phone 916-396-5309 <br /> Address 2255 Contra Costa Blvd, Ste 312 city/stats/zip Pleasant Hill,CA 94523 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapo(/Water) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Ila: Casirp Dia: Casing Depth: <br /> ❑ INJECTION(Air Sp,w Om») ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mmdmun Freefail Depen Is 30 Fq <br /> WE IJ SOIL BORING Ips GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 ®OVER-BORE DIAMETER of 20 inches to depth of 55 feet <br /> WELL ms EVVNA1 EVVNA3 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS Cement bentonite grout ❑EXPLOSIVES From to feet Wow surface <br /> ­ .Tn ac r IQPF n el IrFaC n Hr)SF WI PIPE ®MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> previously SJCEHD approved plan to over drill the wells (and associated gravel and sounding pipes) inside the conductor <br /> casings, and then attempt to remove the conductor casing at EWNA3 (no seal present). The conductor casing at EWNA1 <br /> has a seal and removal will not be required. <br /> San"n <br /> Lowey..�..... ... <br /> _. _ ... <br /> Signed Title/Company Sr.Geologist, Program Manager/Ahtna Environmental, Inc. <br /> Print Name ache)Kerr, PG Date August 19,2020 <br /> ' ENT SE LY �i <br /> A0pplication By-.- Date Issued: a Z� <br /> s o � <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: vv <br /> Facill /S" IrrformaU <br /> FA Nane FA Address C) FA# 0 0 Z#,j TPR# A <br /> FA PE <br /> 7116 1a�/tl l2 ,� WP Reviewed By V j Work Date <br /> ❑G57 ❑C-57 AAorIzaIIoo kx OVW l0 ftn P&TrA ❑Workers Camp ❑Waker's�CoirpWaiver ❑ cro <br /> Enachment Permit ❑ ss AxasAAgmement [,Lead Agency ApproA [3 MFR <br /> COMME <br /> NTS/CONDITIONS: I 'f,1 1 Q rm;k -5 , kr ,A k-.��KII 1 '46 Frne�Yit/l <br /> 4J ! 0(�?j$t1_40 � -f'� re,Vislt� ✓"-&1441 i (0/1-2 © <br /> w C���► <br /> WP TYPE I PE SC I FEE INFO AMT REMITTED1 CHECK*I RECV'D BY DATE pW,�•ELL PERMIT* INVOICE# <br /> Permit if ci , l.j $152 x M _> `"C G 0(S la W f"O LHI .5—Z. <br /> 1868 E. Hazelton Avenue I Stockton, California 9520o2,25-4-�W5� j 209t 468-3420 l F 209 464-0138 1 www.sjcehd.com <br /> EHD2fl"01 0"1-17 l I • � ...-S MItIg#.II=,�Well P"[ApPllcatJon <br />