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V /�1 <br /> pIpWN C ( r V <br /> S A N JOAQUIN Environmental Healthpt <br /> ,n 7 <br /> " COUNTY— ?? <br /> cgrjP 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 3081 North Tracy Boulevard CitylState/Zip Tracy/ CA / 95376 Phone (415) 617-5791 <br /> Crossstreet West Clover Road APN 214-180-41 <br /> Property Owner• Loja Tracy, LLC Phone (415) 617-5791 <br /> Address 3439 Brookside Rd, #108 City/State/ZIP Las Vegas / NV / 89137 <br /> 0-57 Contractor Environmental Control Associates License# 695970 Phone (831) 662-8178 <br /> Address 3011 Twin Palms Drive City/State/Zip Aptos / CA / 95003 <br /> Partner Engineering and Science, <br /> Consultant/Sub-Contractorinc. License# Phone ( 661) 316-8237 <br /> Address 2154 Torrance Boulevard City/State/Zip Torrance / CA / 90501 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING(sWlVayor Probe) 4 ❑ HOLLOW STEM BORING DEPTH 5feet 18 feet ® BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ® EXTRACTION(Vapunlifater) 5 ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25"/10 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE - ❑ MUD ROTARY CASING THICKNESS Schad.40/4°dla. TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CM) CONDUCTOR CASING ❑Yes.❑No noting Dia: Casing Dla: Casing Depth: <br /> ❑ INJECTION IAi spare..Ozoirel ❑ HANDAUGER GROUTSEALDEPTH Approx.2' TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑ PIPE <br /> ❑ OTHER SVE-5, SVE-8, ❑ OTHER; GROUT SEAL PUMPED? ElYes ®No (Note:Maximum Freelall Depth Is 30 Ft) <br /> SVE-B, SVE-9, <br /> WEU/SOIL BORING as SVE-7 SG32,SG33,SG34,S1335 GROUT SPECIFICATIONS Neat Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDs —[I PRESSURE GROUT To depth of feelbelm surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to feel 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 /> Signed Title/Company Senior Project Manager/Partner Engineering and Science Inc. <br /> Print Name Debbie Soukup Date February 8, 2018 <br /> D PARTMENT USE ONLY <br /> Application Accepted By: � Date Issued: to,, <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name 1t,.1 ckc& FA Address � ()r[ I 1d `rt+l�.� 61YA FA# 0 1,4 PR# <br /> � LYS '� 'I•Z3 � <br /> FA PE !�(� WP Reviewed By D L X Work Plan Date <br /> 4 <br /> ❑G57 C-57 Authorization for Other to Sign Permit erker's Comp ❑Wo&ees Comp Waiver ❑Encroachment Permit AceessAgreement Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D 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-M 08-01-17 Site MIIlgallan Well Permit Application <br />