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Job Address Central Parkway Mountain City/State/Zip House, CA 95391 <br /> <br />Cross Street N/A <br /> APN 209-06-048 <br />Title/Company Staff Engineer/ ENGEO <br />Date 1/08/2019 <br />Signed <br />Print Name_ Kofi Bonner <br />C'N- 4f.-• SANAOAQOIN <br />COUNTY <br />ts,6A0--et, Z5 <br />gnvironmental Health Department <br />Greatnrss crows 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 />Property Owner* Century Communities - Jeff lnabnit <br />C-57 Contractor PeneCore Drilling, Inc <br />Address 220 N East St City/State/Zip Woodland, CA 95776 <br />Consultant/Sub-Contractor <br /> ENGEO - Shawn Munger <br />Phone <br />Phone <br />Phone <br />Phone <br />925-239-6932 <br />925-239-6932 <br />530-661-3600 <br />916-580-6535 <br />Address 4701 Sisk Road, Suite 103 City/State/Zip Modesto, CA 95356 <br /> <br />License# 906899 <br />License# CA CHG #413 <br />Address 2213 Plaza Drive City/State/Zip Rocklin, CA 95765 <br /> <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 />El MONITORING El HOLLOW STEM BORING DEPTH 3a10' .1W 40' <br />EXTRACTION (VaporMater) IS HAMMER/DRIVEN DIA. OF BOREHOLE 4" <br />SOIL VAPOR PROBE 3 D MUD ROTARY CASING THICKNESS None <br />IS SOIL BORING 1 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No <br />INJECTION (Air Spam Ozone( 0 HAND AUGER GROUT SEAL DEPTH <br />OTHER 0 OTHER: GROUT SEAL PUMPED? El Yes 0 No <br />WELU SOIL BORING IDs GROUT SPECIFICATIONS <br />50-1,SG-2,SG-3 @10 GW-1@40' <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />o MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <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 /> <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br /># WELLS TO BE DESTROYED None, semi-permanent D OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs SG-5,SG-11,SG-12 @10' GW-1@40' El PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS flezet-- Ceme4,-*---•o-y-,A.,-/ 0 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED I=I AUGERS El HOSE MPIPE f 0 MUSHROOM CAP I=I 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />3 soil gas wells all at 10 feet, 1 grab groundwater boring at 40 feet <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 />Application Accepted By: (6 <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />DEPARTMENT USE ONLY <br />11\ Date Issued: <br /> <br />E 200 <br /> <br />FA Name FA Address :2:33-3G .vyko.44..,6{.04‘,,A FA# fiocx,i g 54, <br />-.I '... <br />toil co 7984 / Lt <br />FA PE WP Reviewed By vc— Work Plan Date ) / 4 / q <br />C-57 0 0-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />fir- pn--b5 0004 <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit 2A 05- -33 $152x 3 9 510 .6D Go Po 0 39 (IT <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />SY20 9_96-3 ow2,Lca, )