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S A N J O A Q U I N E vi 6"oI15'i'l e ital Health Departmeri L 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 ,1,8 Pours 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 In front of 455 Palm Circle(Alden Park Site) City/State/Zip Tracy, CA 95376 Phone Rob Moniz(Arcadis)925-78e-7377 Cross Street Centre Court APN 234-160-05 Property Owner* City of Tracy Phone Address 333 Civic Center Plaz city/State/Zip Tracy, CA 95376 C-57 contractor Penecore a k� 7_(;ZqD _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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH _ _❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN 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 Die: Casing Die: Casing Depth ❑ INJECTION(Air Soave.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: DE TRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 _ OVER-BORE DIAMETER of inches to depth of feet WELL IDs M W-12 ` RESSURE GROUT To depth of 20 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 ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: Installation Date:04/27/87 PVC Casing Depth:20 ft Screen Interval:5-20 ft Total Depth: 0 ft PVC Casing Diameter:4 in Annular Seal Interval:1-4 ft I hereby ertify 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 Print Name Date_ DEFARTMENT USE ONLY �j� Application Acc/By/Dates: By: Date Issued: ��[ �—f/ 64 Grout Inspectio Destruction Inspection By Al Facilit /Site Information FA Name al/�-- �� FA Address s� FA# 0 O 0 6 �' g g PR# 1,0,50 S T(� FA PE ZA O Z WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS:^ . l/ c WP TYPE I PE I SC I FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# PermitNO 2 3 $152 x / t Z : /ryt ih4l 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 4614C14F 209 464-0-1 338 1 vvwvd.sjcehd.com I EHD 29-07 OB-01-17 lipGcation