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SAN.,JOAQUIN p } 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 3081 North Tracy Boulevard City/state/zip Tracy/ CA / 95376Phone (415) 617-5791 cross Street West Clover Road APN 214-180-41 Property Owner' Loja Tracy LLC Phone (415 ) 617-5791 Address 3439 Brookside Road #108 City/State/Zip Stockton/ CA / 95219 Z/ZA '1p C-57 Contractor EnProbe Environmental Drilling Services License# 1012248 Phone Jam✓ —��C.{` Address P - O. Box 6093 City/State/zip Oroville / CA / 95966 ConsultanUSub-Contractor Partner Engineering and science, inc.License# Phone ( 661 ) 316-8237 Address 2154 Torrance Boulevard City/State/zip Torrance / CA / 90501 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BodngsNVelis Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH IN BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporMater) _ _❑ HAMMERNRIVEN DIA.OF BOREHOLE _❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA SOILVAPORPROBE _ _❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER U SOIL BORING ❑ PUSH POINT(GPI CPI) CONDUCTORCASING ❑Yes INo Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION nswrce.exoirol ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: [I AUGERS El HOSE El PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes [I No (Note:Maximum Fmerall Depth is 30 FI) WELIJ SOIL BORING IDs IGROUT SPECIFICATIONS _ p,DESTRUCTION WORK TOBEPERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DE TROYED [a OVER-BORE DIAMETER of3 . 25 inches to depth of 5 . 5 feet A/OWELLIDs SO, SG' 2, 5 3 SG SGM , SG 9 El PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat Cement [I EXPLOSIVES From_to feet below surface TREMIE TYPE TO BE USED ElAUGERS ElHOSE ElPIPE ❑MUSHROOM CAP El3 feet below surface or feet below surface if>3 feet COMMENTS: 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. NSigned Title/Companycrc;ecc uanager / Partner Engineering and Science, Inc. ote PdntName Daniel Monteverde Date May 8 , 2020 j�Akt+We :f llLr{' "Sc. 4- fC#W5 //'t .(,1it�; t DEPARTMENT USE ONLY Z %krrSiOApplication Accepted By: Dale Issued: W�� Grout Inspection By/Dates: Destruction Inspection By/Dales: i Zo V((,rlia[CONIMENTSIC ilit /Site Information (� Name j,,,'0p,� � FA Address 30$/ Al. Tic FA# 00�� I ` PR# b� ' Z31 PE 5a WP Reviewed By / Work Plan Date 0C-57 G-57 Authorization for Other to Sign Pem01 ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval LOMER NDITIONS: SMktlw� rincurred itrgcbiu�q re�br- 7%IYj��-lT M-� S,.tl7hti-�. f v�tll {� }�iI e1 tr� .�1.f2�b.r.r�r ge WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 20 3i3 $152x _!5A C,C � Od 1868 E. Hazelton Avenue I Stockton, California 95205 I i 209 468-3420 1 F 209 464- j j ehkd.COm EH02911108-0I-17 Site Mitigation Well Permit Application