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.SA N !O A Q U I N Erwirormiental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Reinediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4i"; �soars Advance Notice Required For All lnspectk;t ,:> 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 Lawn Area of 580 Palrn Circle (Alden Park Site) City/State/Zip Tracy, CA 95376 Phone Rob Moniz(Arcadis)925-7BB-7377 Cross Street Centre Court APN 234-160-10 Property Owner* City Of TracV Phone Address 333 Civic Center Plaza City/State/Zip Tracy, CA 95376 C-57 Contractor Penecore �g_�� License# 906899 Phone (530)661-3600 Address 220 N. East Street City/State/Zip Woodland CA 95776 _ Consultant/Sub-Contractor Rob Moniz-Arcadis License# Phone 925.788.7377 Address 2300 Clayton Rd, Suite 400 City/State/Zip Concord,CA 94520 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Aa span..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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 1 OVER-BORE DIAMETER of inches to depth of feet WELL IDS MW-11 RESSURE GROUT To depth of 22 feet below surface GROUT SPECIFICATIONS Neat Cement(94 lb bag/5-6 gal water) ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE N PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: Installation Date:04/27/87 PVC Casing Depth:22 ft Screen Interval:7-22 ft Total Depth:22 ft PVC Casing Diameter:4 in Annular Seal Interval:1-6 ft hereby certfi that I am authorized to complete this application and that the work will be done in accordance with Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Print Name Date Y- DEPARTMENT USE ONLY / Zd2 Application Accepted By: C11 A Date Issued. G Grout Inspection By/Dates: Destruction Inspection By/Dates: l CP Zc� Facilit /Site Information FA Name 1 FA Address C/o -� tJ` [FA# 0006q9,5PR# 0 FA PE ?f 90 WP Reviewed By _ A 7 Work Plan Date ElC-57 ❑C-57lAuthorization for Other to Sign Permit ❑Worker's Camp Cl Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement [--]Lead Agency Approval ❑MFR 1 COMMENTSlCONDITIONS: CC- WP TYPE PE SC FEE INFO JAMT REMITTED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 0 513 1$152,, Z C C 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 466fit�2 F 209 464- �� QV d. corn f EHO 29-01 0"1-17 Site Mitigation Well Permit Application