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S A N J O A Q U I N Environmental Health Department COUNTY cquFoa�`,y Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation AUG 31 REC'. 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 / 95376 Phone (415) 617-5791 crossStreot West Clover Road APN 214-180-41 Property Owner* Loja Tracy, LLC Phone (415) 617-5791 Address 3439 Brookside Rd, #108 City/Statelzip Las vegan / NV / 89137 C•67 Contractor Environmental Control Associates License# 695970 Phone (831) 662-8178 Address 3011 Twin Palms Drive city/state/Zip Aptos / CA / 95003 Partner Engineering and Science, Consultant/Sub-Contractor Inc. License# Phone ( 661) 316-8237 Address 2154 Torrance Boulevard City/State/Zip Torrance / CA / 90501 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsfWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 8feet ® BOLTED TRAFFIC BOX ❑STOVE PIPE 0 EXTRACTION(Vapor/Water) 4 ❑ HAMMERIDRNEN DIA.OF BOREHOLE 8inches ❑ MULTIPLE CASINGS❑ MULTtLEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Schad.40/2'dla. TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dla: Casing Depth: ❑ INJECTIONrAe Soarae.ozoeel ❑ HANDAUGER GROUTSEALDEPTH Approx.2' TREMIE TYPE TO RE USED: ®AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes.M No (Note:Madmum Freefall Depth is 30 FI) WELL/SOIL BORING IDs SVE-1, SVE-Z SVE-3,SVE-4 GROUT SPECIFICATIONS Neat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE ❑ MUSHROOM CAP ❑3 feet below surface or feet below surface d>3 feel 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. Signed "'- \ Title/Company Senior Project Manager/Partner Engineering and Science,Inc. Print Name Debble Soukup Date August 24, 2017 DEPARTMENT USE ONLY Application Accepted By: iy-'Q'1, / Date Issued: /( 1 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name �Crrl"A} I e `�S FA Address 3 Dii I h� t�T-� Q Ivd� FA# (70 L3� tC'1 PR# GTSy I LS FA PE ,l i j tI l WP Reviewed By L —}f Work Plan Date 0C-57 C57 Authorization for Other to Sgn Permit Rglkoes Comp ❑Workers Comp Waiver ❑ Encroachment Permit ccess Agmement end AgencyAppmval 9KFR COM M ENTSICON DITI ONS: WP TYPE I PE I SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit r2`W I $152 X '-I fa() d-tYb48 Lx tl l' I'l W PW3i2 1868 E. Hazelton Avenue I Stockton, California 95WFt 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 09-01-17 Site Miagauan Well Permll Applicacon