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I SAN JOAQUIN 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 3379Nodh Tracy Boulevard City/State/Zlp Tracy.CA q Phone NA Cross Street West Clover Road APN 214-180-210�000 Properly Owner* tJ Remainder LLC Phone Address 9505VWfamsburg Plam3O0 City/State/Zip Louisvllle,la40222 C-57 Contractor Cascade Drilling License# 1059336 Phone (916)638.1169 Address 3000Duluth Street City/State/Zip West Samrnenlo,CA Consultant/Sub-Contractor Slantec Consultirg Services,Inc, License# Patrick McCannell,PG720.5 Phone (858)63&4222 Address 9665Granite Ridge Drive Suite 220 City/State/Zip San Diego CA92123 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) D HAMMERNRNEN DW.OF BOREHOLE 225 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 5 ® PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes [I No Boring Dia: Casing Del: Caging Depth: ❑ INJECTION&Soarae Omre) 0 HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑AUGERS El HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:MaxYnum F�pg(yll�eA i,3a Ft) WELD SOIL BORING IDS SB-1lhrough SBS GROUT SPECIFICATIONS aoreholes mll be backfilletl wi neat semen sing PVC casing fdlovdng soil a.groundwater sample mlledion DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth of feel WELL IDs ❑PRESSURE GROUT Todepthof_feelbelowsudace GROUT SPECIFICATIONS [I EXPLOSIVES Fran_to—feet below surface THEME TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>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 Pd, pal GedWistrtantac Consulting SeMms,Inc Print Name Patrick McConnell Date Wl2nO20 PARTMENT USE ONLY Application Accepted By: Dale Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facillt /Site Information ��nA FA Name _ FA Address 3? N. �yyk C FA# O FA PE WP Reviewed By J f Work Plan Date 0C-57 G57Aulthoftation Ior Olherto Sign Permit ❑Workers Comp []Workers Comp Wrier ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/ NDITIONS: SDI- N1: /, try �f Lr'� •�— e,Lw�,�-& r, p � * Ltr r 1IUU (�C C- / jVVPTYPEj PE I SC FEE INFO JAMTREMITFDI CHECK# I RECV'D eY DATE IdELLFfRMIPL, INVOICE# Permit17,4051313 1152 X k- 02 3 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 46,F 1 8 . c hd.com EHD 29-0I 0"147 Site Mitigation Weg PennitApplication