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S A N JOAQUIN Environmental Health Department <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Sidewalk in front of 1423 Birch Drive(Alden Park Site) City/State/Zip Tracy, CA 95376 Phone Rob Moniz(Arcadis)925-788-7377 <br /> Cross Street Chesnut Avenue ApN 234-150-13 <br /> Property Owner' City of Tracy Phone <br /> Address 333 Civic Center Plaza City/State/Zip Tracy, CA 95376 <br /> C-57 Contractor Penecore _ License# 906899 Phone (530) 661-3600 <br /> Address 220 N. East Street City/State/Zip Woodland, CA 95776 <br /> Consultant/Sub-Contractor Rob Moniz-Arcadis License# Phone 925.788.7377 <br /> Address 2300 Clayton Rd, Suite 400 City/State/Zip Concord, CA 94520 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL.VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Alr Soaroe.Ozone/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ O T HFR_ _ GROUT SEAL PUMPED? ❑Yes❑No (Note:Maximum Freelall Depth is 30 Ft) <br /> WELL/SOIL BORING IOs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 �;4VER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs MW-14 _ _ RESSURE GROUT To depth of 20 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement(94 lb bag/5-6 gal water) ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE 2 PIPE ®MUSHROOM CAP 93 feet below surface or feet below surface if>3 feet <br /> COMMENTS: Installation Date:04/28/87 PVC Casing Depth:19 It Screen Interval:4-19 ft <br /> Total Depth:20 It/ PVC Casing Diameter:4 in Annular Seal Interval:1 -3.5 It <br /> I hereby ce that 1 am authorized to complete this application and that the work will be done in accordance with <br /> n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company <br /> Print Name !/ — Date //,7 <br /> DEB6RTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site lnformation C� <br /> FA Name lcen �ar r FAAddress SHOO v�� FA# 000 6 L?g$ P R# <br /> 1 <br /> FA PE D V WP Reviewed By /, `1 Work Plan Date / <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp [:)Worker's Cornp Waiver ❑Encroachment Permit [:]Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: C.0 . 01����' <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit J l 152 x CdWj I of nat) 14 <br /> 1 60 E. I-lazelton Avenue j Stockton, CaiifOr nla 952'D5± T 209 468­3420 j F 209 464- ) r✓�ti• .sj S .COiT1 <br /> EHO 2"l 08-01-17 Site Mitigation Well Permit Application <br />