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SAN -J 0 A Q U IN Environmental Health Department COUNTY Greotnes5 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/95337 Phone N/A Cross Street Airport Road APN N/A Property Owner' City of Manteca Phone Address City/State/zip Manteca, CA 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 BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) ❑ 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 Soarae.Ozone l ElHAND 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 6 inches to depth of 2 5.1 feet WELL IDs PZ017 and PZ019 ❑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 [:13 feet below surface or feet below surface if>3 feet COMMENTS: TD 25.1 for both wells 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 DEP ARTMENT USE ONLY Application Accepted By: r l/ Date Issued: Grout Inspection By/Dates: QQ Destruction Inspection By/Dates: Facilit /Site Information FA Name rpt"r FA Address , FA# PR# FA PE S� S WP Reviewed By L_ Work Plan Date 3/c 1Y ❑C-57 [1057 Authorizafion for Other to Sign Permit ER' orkers Comp ❑Worker's Comp Waiver la-I�incroachment Permit ❑Access Agreement [ij,'ad Agency Approval [a4FR COMMENTS/CONDITIONS: l t n^t -;at� , 5„p S,,A -k- 3 s -��kAw ,:1 WP TYPE PE Sc FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit Z,(.) 13 $152x Z 3 C`1 319V �V �P��3b' tliL 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 }- Site Mitigation Well Permit Application „� 2v1o3 S Z� lSZX3 75 SSS L-A ��te � tg SkZ"'I'l it -1