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SA6JQQQQIN Environmental Health Department <br /> —COUNTY <br /> G­,o­ o—ws here. <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 Approximately 16051 to 16407 McKinley Avenuecity/State/Zip Lathrop, CA 95330 Phone NA <br /> Cross Street East Louise Avenue APN NA; City of Lathrop Right of Way <br /> Property Owner* City of Lathrop Phone 209-941-7430 <br /> Address 390 Towne Centre Drive City/State/Zip Lathrop, CA 95330 <br /> C-57 Contractor Gregg Drilling License# C57-1044456 Phone 925-313-5800 <br /> Address 950 Howe Road City/State/Zip Martinez, CA 94553 <br /> Consultant/Sub-Contractor Geosyntec Inc. License# NA Phone 916-637-8048 <br /> Address 3043 Gold Canal Drive, Suite 100 City/State/Zip Rancho Cordova, CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑ HOLLOW STEM BORING DEPTH Z ❑BOLTED TRAFFIC BOX ®STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN 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(GPI CPT) CONDUCTOR CASING []Yes No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IXJ PIPE <br /> ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs Boring:B-11 GROUT SPECIFICATIONS Type II-V <br /> Well:PW46 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [-]AUGERS ElHOSE [:]PIPE [IMUSHROOM CAP [_13 feet below surface or feet below surface if>3 feet <br /> COMMENTS: 1 monitoring well will be installed to a maximum depth of 300 ft bgs. See attached table with well specifications. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> -. San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Senior Geologist/Geosyntec Consultants,Inc. <br /> Print Name Nicole Gotberg Date February 28,2019 <br /> TMENT USE ONLY <br /> Application Accepted By: Date Issued: �Z�� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name S , FA Address 11011 f� FA# e�0 Zy`� PR# 0S�j S-La <br /> FA PE Z.��j J WP Reviewed By L-- —x Work Plan Date 1 / <br /> ❑C-57 57 Authorization for Other to Sign Permit 21orker's Comp ❑Worker's Comp Waiver 0ncroachment Permit ❑Access Agreement Lk ed Agency Approval FR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO JAMT REMITTED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit Z40 t 31 $152 it 107 �� -4 Z3 l`J (� <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> �P EHD 299-0W1-17SZ 3 I —x t[t^ )' /� /��C� Site Miy�LI UL <br />