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1 > I SANQIOAQUIN a°7� �, Environmental Health Department r. l;ai_'' COUNTY— „ ,.,,,=5' 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 3081 North Tracy Boulevard city/statelzipTracy/ CA / 95376 Phone (415) 617-5791 Cross Street West Clover Road APN 214-180-41 Property Owner* Loia Tracy LLC Phone (415) 617-5791 Address 3439 Brookside Road #108 city/stateizipStockton/ CA / 95219 LP C-57Contractor EnProbe Environmental Drilling Services License# 1012248 Phone S50-V 13-6 11 q Address P . O . Box 6093 city/stateizip Oroville / CA / 95966 Consultant/Sub-Contractor Partner Engineering and Science, Inc.License# Phone ( 661 ) 316-8237 Address 2154 Torrance Boulevard city/state/zip Torrance / CA / 90501 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BorfngsAA/ells Require Access Agreements or Encroachment Permits 0 TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 51 / [K BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXFRACTION(VapoclWater) ❑ HAMMER/DRIVEN DIA.OFBOREHOLE 2 - 25n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA LSD SOILVAPORPROBE 4 0 MUD ROTARY CASINGTHICKNESS TYPEOFCASING: [I STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes NNo Boring Dia: Casing Dia: Casing Depth: ❑ INJECTIONwsoxae.Ozalel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes [I No (Note:Maximum Resist Depth is 30 Ft) WELL/SOIL BORING IDs _qr- ROUTSPECIFICATIONS Neat Cement It�W,,-iu� zc'./ IOA 11Q1 "IAZZ4 lv +•wVi P. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY)---, #WELLS TO BE DESTROYED_ _ _ OVER-BORE DIAMETER of; inches to depth of _ __feet VI1►WELLIDs SI _LI PRESSURE GROUT To depth of metbelowsudace 7 GROUT SPECIFICA I IONs__ El EXPLOSIVES From to feet below surface TYPE TO BE USED ❑AUGERS LJ Hubt L]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 j San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. -'>Signed Title/Company project mnager / Partner engineering and science, Inc. NOie Print Name Daniel Monteverde Date May 8 , 2020 SS4tkwe- ;t tr_{YURrc- +- ofFeA s /H Zola,". L DEPARTMENT USE ONLY versiWpplication Accepted By: Date Issued: �"��,�r'�Grout Inspection By/Dates: Destru tion on ff'%top X/r-rCoMMENTSIC c/She Inform atio///nJ/Dates: p e (DYAter0,AA'<TFAAddress 30YI N. �/rLG FA# OO Z3 I \ PR# 05L41231 WP Reviewed By Work Plan Dale 2/4—/ZD❑G-57 C-57 Augwrization for Other to Sign Permit ❑WodmrsComp ❑WorkersCompWaiver ❑EncroachmentPermit ❑AcoessAgreement ❑Leard�AgencyApproval ❑MFR ND{TIONS: G �.� rypy��if/�s,4 $ -f'O 5-11 �Y !Ol/e4 garL IOVL 13, 3.n 'u.m +0 kewillq rQ0ert7/ryf0( (5 A# $ Abnt;*J vj' �C IL 44— -1 f2.Gv.+ (* vJh�e _ reArir WP TYPE I PE I SCL FEE INFO JAMT REMITTEDI CHECK# I RECV'D BY DATE WELL PERMIT# I INVOICE# Permit 2ao1 313 $152x 3 D S Z3 W 0� 10 s� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464- l jFeh�d.COn1 EHD 29-01 oaal-17 Site Mitigation Well Permit Application