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SANJOAQUIN <br /> Environmental Health tp <br /> COUNTY— 1 <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATIOWf Ik4 <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 3081 North Tracy Boulevard City/State/Zip Tracy/ CA / 95376 Phone (415) 617-5791 <br /> Cross Street West Clover Road APN 214-180-41 <br /> Property Owner* Loja Tracy, LLC Phone (415) 617-5791 <br /> Address 3439 Brookside Rd, #108 City/Slate/Zip Las Vegas / NV / 89137 <br /> C-57 Contractor Environmental Control Associates License# 695970 Phone (831) 662-8178. <br /> Address 3011 Twin Palms Drive city/Statelzip Aptos / CA / 95003 <br /> Partner Engineering and Science, <br /> Consultant/Sub-Contractor Inc. License# <br /> Phone ( 661) 316-8237 <br /> Address 2154 Torrance Boulevard City/State/Zip Torrance / CA / 90501 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 19 MONITORING(&it ww Probe) 4 ❑ HOLLOW STEM BORING DEPTH 5 feet/8 feet N BOLTED TRAFFIC BOX El STOVEPIPE <br /> ® EXTRACTION(VapodWater) 5 ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.25'/10 inches ❑MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE - ❑ MUD ROTARY CASING THICKNESS Schad,40/4"dia. TYPE OF CASING: El STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING El Yes [I No Boring Dia: Casing Dim: Casing Depth: <br /> ❑ INJECTION(Airaoxne.Ozone/ ❑ HAND AUGER GROUTSEALDEPTH ApproX.2' TREMIE TYPE TO BE USED: ®AUGERS El HOSE El PIPE <br /> ❑ OTHER ❑ OTHER; GROUT SEAL PUMPED? ❑Yes ® No (Note:Maximum Foretll Depth is 30 FI) <br /> SVE-5, SVE-B, <br /> SVE-6, SVE-9, <br /> WELU SOIL BORING IDs SVE-7 SG32,SG33,SG34,SG35 GROUT SPECIFICATIONS Neat Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: /CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> �c� .bvr`aue' <br /> Signed Title/Company Senior Project Manager/Partner Engineering and Science Inc. <br /> Print Name Debbie Soukup Date February 6, 2018 <br /> DEPARTMENT USE ONLY / V <br /> Application Accepted By: �„-.- Date Issued: J /j Z � �A <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name Q At it dt&✓ -c4 FA Address j �?Q 1 N rft4 N%VA FA# f70231e (.4� PR# CSq tz.3 j <br /> FA PE jfii_ J tl WP Reviewed By D —X Work Plan Date �, I U <br /> ❑C-57 C-57 Authorization for Other to Sign Permit orkel's Comp ❑Workers Camp Waiver ❑Encroachment Permit Access Agreement Lead Agency Approval ❑ MFR <br /> COMMENTS/CONDITIONS: <br /> WPTYPE PE_]_ SCT FEE INFO AMT REMn­T­EDj CHECK# RECV'O BY DATE WELL PERMIT# INVOICE# <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 0"1-17 Site Mitigation Well Permit Application <br />