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Job Address 18 E. 11th Street City/State/Zip Tracy, CA 95376 <br />Phone NA <br />Cross Street N. Central Ave APN 235-171-03 <br />Phone 206-779-4877 Property owner. Nathaniel Papadakis <br />Address 2502 27th Ave W Seattle WA 98199 City/State/Zip <br />Phone <br />Licensett C574 485165 C-57 Contractor Gregg Drilling Co <br />Phone 800-385-7105 <br />Martinez, CA 94553 City/State/Zip <br />License CA PG # 7456 <br />Address 950 Howe Road <br />Consultant/Sub-Contractor Fulcrum Resources/John Winkler <br />RECE WED <br />FEB 23 2017 <br />ENVIRONMENTAL HEALTH <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 PERM1T/SERVICE8 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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 />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 Standard& <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Address 517 S Ivy Ave City/State/Zip Monrovia, CA 91016 <br />AUGERS 0 HOSE rj PIPE <br />DESTRUCTION WORK TO BE PERFORMED; DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED El OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS 0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP p 3 feet below surface or feet below surface if >3 feet <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />CONSTRUCTION WORK TO BE PERFORMED: *Note. Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TREMIE TYPE TO BE USED <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D HOLLOW STEM BORING DEPTH 15 FT <br /> LI HAMMER/DRIVEN DIA. OF BOREHOLE 2 INCH <br />4 ci MUD ROTARY CASING THICKNESS <br /> M PUSH POINT (GP/CPT) CONDUCTOR CASING CI Yes 0 No <br />p HAND AUGER GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes ID No <br />GROUT SPECIFICATIONS <br />TYPE OF WELL/BORING <br />ID MONITORING <br />Eli EXTRACTION (VaporMater) <br />M SOIL VAPOR PROBE <br />0 SOIL BORING <br />0 INJECTION (Air Spame, Ozonai <br />ID OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs SH1, SH2, SB3, SB4 <br />COMMENTS: <br />that 1.nraUttiorIzell:tp, complSe ttAs,q0plIca_Boy$4111#1440fittirLtg.1011.!1:1,OftIOtfOlk,v4usOrtIa9culyItti_, <br />oaquln County OrdInanco poclos ancUStandardisi aritraltottiei-appgcablikGalifortila <br />Title/Company Project Geologist Fulcrum <br />Date 2/21/17 inkier <br />I herebL,c4n1f4 <br />Signed <br />Print Name John <br />LI BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: ID STEEL D PVC D OTHER <br />Boring Dia: Casing Dia: <br />TREMIE TYPE TO BE USED: 0 AUGERS I:1 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth Is 30 It) <br />Casing Depth: <br />DEPARTMENT USE ONLY <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FM PR <br />FA PE WP Reviewed By-F. Work Plan Date <br />D C-57 0 c-57 Authorization for Other to Sign Permit 0 Workers Comp 13 Worker's Comp Waiver D Encroachment Permit CI Access Agreement 0 Lead Agency Approval 0 MFR <br />, r c OMMENTSICONDITIONS: (.;. c 111.,,,...), 11...B.viv:YL 1:L.,k,, .,i.,.j.)-„,;,, L - , L . at,— /../ iy,' 7 <br />i 1;,,,,124-.1,,,t,4) 0,-- <br />SR T`IPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit Tej .., t- ' , $139x - <br />., <br />„- <br />, <br />-i <br />#: <br />1 <br />• ' <br />./ -- <br /> -- I <br />•t 7 .N .7 <br />(:(.) 7(.1 7 6. - <br />Site Mitigation Well Permit Application <br />2- y 0 .±.) <br />1 /7 <br />EHD 29-01 10-26-2015