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El BOLTED TRAFFIC BOX D STOVE PIPE <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />2.5" ip MULTIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA HAMMER/DRIVEN DIA. OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br />Di PUSH POINT (GP/ CPT) CONDUCTOR CASING 3 <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? El Yes Cg No <br />GROUT SPECIFICATIONS <br /> 0 HAND AUGER <br /> o OTHER: <br />SG-5, SG-6, SG-7 <br />TYPE OF WELL/BORING <br />El MONITORING <br />12 EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />M SOIL BORING <br />INJECTION (Air Seam Ozone( <br />OTHER <br />WELU SOIL BORING 1Ds <br />NA TYPE OF CASING: 0 STEEL 0 PVC DI OTHER <br />ID Yes ID No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: D AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />or, <br /> <br />SAN JOAOUiii <br />Environmental Health Department <br />COUNTY <br />7-1.,Fock7 Greatness grows 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 371 S Garfield Ave City/State/Zip Manteca, CA 95336 Phone NA <br /> <br />Cross Street Moffat Blvd APN 221-08-040 <br /> <br />Property Owner* Manteca Unified School District Phone 209-825-3200 <br />Address 2271 W Louise Ave City/State/Zip Manteca, CA 95337 <br /> <br />C-57 Contractor Gregg Drilling <br /> <br />License# 485165 Phone 925-313-5800 <br /> <br />Address 950 Howe Rd <br /> <br />City/State/Zip Martinez, CA 94553 <br /> <br />Consultant/Sub-Contractor Terraphase Engineering <br />Address 1404 Franklin St, #600 <br /> <br />License# Phone 510-645-1850 <br /> <br />City/State/Zip Oakland. CA 94612 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 3 borings <br />WELL IDs NA <br />GROUT SPECIFICATIONS neat cement <br /> <br />TREMIE TYPE TO BE USED El AUGERS 111 HOSE EXI PIPE <br />COMMENTS: Soil borings advanced with post run tubing for soil-gas sample collection. Soil borings to be grouted starting from the <br />total bottom depth up to the surface <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 <br />Print Name Daren Roth Date 7/25/18 <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />1=1 EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />Title/Company Senior Project Geologist, Terraphase <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Date Issued: ( I's r -el <br />DEPARTMENT USE ONLY <br />FA Name 4.> J; ;v1 '+Zc1 /4,8--- 3 I vd FA Address 3 1 ) C C.,-,4 t td iv, FA# 0 02,4 1 i 9 PR# <br />FA PE 2-9 go <br />WP Reviewed By /— V Work Plan Date -1 i 7,E1 a <br />0 C-57 EiC7 Authorization for Other to Sign Permit IR‘orker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement f: Lead Agency Approval ga41FR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit .) 16,c si $152x 3 $ 4,533 i1/4011 \ <br />is/ I 8((g \/•)e00 V43-1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />e tr-32.14) cz-3 4 151 /3 4.4, 6/(0/16.