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SAN.n10AQ IN EnAr®nmental Health Department COUNTY c P ae1 Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and RemediatJUG 3 1 REC-0 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 CitylState/Zip Tracy/ CA / 95376 Phone (415) 617-5791 Cross Street West Clover Road ApN 214-180-41 Property Owner' Loja Tracy, LLC Phone (415) 617-5791 Address 3439 Brookside Rd, #108 City/State/Zip. Las Vegas / NV / 89137 C•67 Contractor Environmental Control Associates License# 695970 Phone (831) 662-8178 Address 3011 Twin Palms Drive CitylState/Zip Aptos / CA / 95003 Partner Engineering and Science, ConsultanUSub-Contractor Inc. License# Phone (661) 316-8237 Address 2154 Torrance Boulevard City/State/Zip Torrance / CA / 90501 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 5feet ®BOLTEDTRAFFIC BOX ❑ STOVEPIPE ❑ EXTRACTION(Vapor/Water) ❑ 14AMMEPJDRFVEN DIA.OF BOREHOLE 2.25 inches ❑ MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA W SOILVAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS .25"nylaflow tube TYPE OF CASING: ❑STEEL ❑PVC ® OTHER Nylaflow tubing ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONOUCTORCASING ❑Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AF spsge 0mnel ❑ HANDAUGER GROUTSEALDEPTH Approx.2' THEME TYPE TO BE USED: El AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes 10 No (Note:Maximum Freefat Depth is 30 Ft) WELD SOIL BORING IDS SG-29 throughSG-31 GROUT SPECIFICATIONS Neal Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO UE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of_feet WELLIDs -[I PRESSURE GROUT To depth offeet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: 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. 0 � Signed Tige/Company Senior Project Manager/Partner Engineering and Science,Inc. Print Name Debbie Soukup Date August 24, 2017 _ DEPARTMENT USE ONLY Application Accepted By: L � �/� Date Issued: ��' 11 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name Q A: �t FAAddress FA# yi3 t, PR# OjLji.231 FA PE WP Reviewed By L.—X Work Plan Dale -A I I I .T ❑ C57 C57 Authoizaton for Other to Sgn Permit .(keel Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ccess Agreement ad AgencyApproval 19'�Fft COMM ENTS/CONDITIONS: WP TYPE PE I SC FEE INFO A11 NIT REMITTED CHECK# RECV'DBY G DATE DWELL PERMIT# INVOICE# Permit 2`it?S at' T' '� $152X 3 4''516 O'1�6`t L-)( _11� )11 �Pj Coo3 ,Z 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 09-01-17 Site Miligalan Well Permit Application