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" �z SWAM I N Department f:_,�.,�� Environmental ealth De � COUNTY °wQP0 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/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 Borings/Wells 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(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(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.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 1 ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs PZ016 ®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: TD 28.5 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 Application Accepted By: DEPARTMENT USE ONLY Date Issued: Ct Grout Inspection By/Dates: Destruction Inspection By/Dates: Z Facilit /Site Information FA Name Sw-P O f— FA Address 0 11?__-l'�' 1e-e) FA# p©-Z y s,-3 PRI �S 2 FA PE WP Reviewed By L X Work Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver ncroachment Permit ❑Access Agreement ead Agency Approval ISR COMM ENTS/CONDITIONS: vtiU-k.� WP TYPE PE SC I FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit �W Z. 313 $152 x t�Z 37y(� �—�� &P Its I 'j Poo jd'Sb.3 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