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Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br /> <br />SAN4NJOAQUIll <br />COUNTY - <br />Greatness grows he,, <br />Environmenwi Health Department <br /> <br />ra. <br /> <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 400 E Yosemite Ave City/State/Zip Manteca, CA 95336 Phone NA <br />APN 221-09-0-0 <br /> <br />Cross Street S Garfield Ave <br /> <br />Property Owner* Manteca Unified School District <br />Address 2271 W Louise Ave <br />C-57 Contractor Gregg Drilling <br />Address 950 Howe Rd <br />Phone 209-825-3200 <br />City/State/Zip Manteca, CA 95337 <br />License# 485165 Phone 925-313-5800 <br />City/State/Zip Martinez, CA 94553 <br />Consultant/Sub-Contractor Terraphase Engineering <br /> <br />License# Phone 510-645-1850 <br /> <br />Address 1404 Franklin St, #600 City/State/Zip Oakland, CA 94612 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />MONITORING <br />EXTRACTION (VaporNVater) <br />SOIL VAPOR PROBE 0 <br />1:4 SOIL BORING 3 IX <br />INJECTION (Air Sorge, Ozone/ 0 <br />OTHER 0 <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 15' <br />HAMMER/DRIVEN DIA. OF BOREHOLE 2.5" <br />MUD ROTARY CASING THICKNESS NA <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No <br />HAND AUGER GROUT SEAL DEPTH <br />OTHER: GROUT SEAL PUMPED? 0 Yes IN No <br />GROUT SPECIFICATIONS SG-2, SG-3, SG-4 <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 3 borings <br />WELL IDs NA <br />neat cement <br />I=1 AUGERS LI HOSE Z1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />LI OVER-BORE DIAMETER of inches to depth of feet <br />LI PRESSURE GROUT To depth of feet below surface <br />I=1 EXPLOSIVES From to feet below surface <br />LI MUSHROOM CAP LI 3 feet below surface or feet below surface if >3 feet <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />COMMENTS: SOH borings advanced by GP with post run tubing for soil-gas sample collection. Soil borings to be grouted starting <br />from the 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 />ieeg <br />Daren Roth Date 7/25/18 <br />Signed <br />Print Name <br />Title/Company Senior Project Geologist, Terraphase <br />DEPARTMENT USE ONLY swit "Iota Date Issued: <br />FA Address -3 -it ) G„..471-e. ici five, FA# 00 2.4 1 -IA PR# os-ti .3 c.:Li <br />FA PE 29s-> WP Reviewed By L Y Work Plan Date --7 i 2_:_s— tk <br />0 C-57 IR657 Authorization for Other to Sign Permit 113‘ker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approva Ili‘R. <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 201,6- -5 i r 5 $152x , '. ---i, 'CV i',) 1 1 , <br />''' <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