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r S A N s)J O A Q U I N Environmental Health Department 44 t� 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 25775 South Patterson Pass Road City/State/Zip Tracy, CA 95377 Phone Cross Street 1-580 APN San Joaquin County.Right of Way Property Owner* San Joaquin County Phone 209-468-3124 Address 1810 E. Hazelton Avenue City/State/Zip Stockton, CA 95205 C-57 Contractor Gregg Drilling and Testing License# C57 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor Arcadis License# Phone 916-865-3171 Address 101 Creekside Ridge Court, Suite 200 City/State/Zip Roseville, CA 95678 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 70 ft bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 2 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ® HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELLI SOIL BORING IDs B-51 and B-52 GROUT SPECIFICATIONS Neat cement from bottom of boring to 6 inches below ground surface. Asphalt patch from 6 inches below ground surface to surface. 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 ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: Encroachment permit is being processed by San Joaquin County Public Works Department and State of California Department of Transportation. 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.Associate Project Manager Print Name Sherrie Lang Date May 24, 2018 DEPART ENT USE ONLY �7 J Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: 2n n W' A nx� Facillt /Site Information FA Name I :'.1�C✓ rh�cwJltiL•�-`cf� FAAddress .Lp�4i� 0 P6 two'^ FA# t90t--i� I L PR# 0Sz-f3 �• FA PES�� WP Reviewed By Work Plan Date S' �, / ❑C-57 C-57 Authorization for Other to Sign Permit orkers Comp [IWorkers Gomp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT## INVOICE# Permit $152 x 3Z,' 1868 azel'2 A e 66 Stockton, C�allfbmia 9d6L j'' Od A&34261 A9 464-01 8 ' www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application