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JUA U1 SITE MITIGATION WELL &BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROMDATE ISSUED filo r{tiltl'F3 % d'1r ni k N41ett;C °;E 5 i- Y!'t >i st' f1t�I l:Ii:t ;: sf�it �033� Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 2532 Dorset Lane City/State/Zip Tracy, CA 95377 phone RobMoniz(Arcadis)925.788-7377 Cross Street Blackbird Court APN 238-300-05 Property Owner ' Mr. and Mrs. Fisher Phone Address 2532 Dorset Lane City/State/Zip Tracy, CA 95377 C-57 Contraor� Penecore .f Q r i (�A License# 906899 Phone Address 220 N. East Street City/State/zip Woodland, CA 95776 Cons ultanUSub-Contractor Rob Moniz - Arcadis License# Phone Address 2300 Clayton Rd Suite 400 City/State/Zip Concord CA 94520 (530) 661-3600 925.788.7377 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite eoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 fl ❑BOLTED TRAFFIC BOX ❑ 5TOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA, OF BOREHOLE 3.5 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA X SOIL VAPOR PROBE �❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC X OTHER Teflon tubing ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (At Spmge Ozw HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes �( No (Note: Maximum Freefall Depth Is 30 Ft) WELL/ SOIL BORING IDs B-12 GROUT SPECIFICATIONS Hydrated Bentonite Grout V to 4'9" in DESTRUCTION WORK TO BE PERFORMEQ: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑ AUGERS []HOSE ❑ PIPE DESTRUCTION II IIVrlllgllVll �T1 FA PE METHOD: V () WP Reviewed By Work Plan Date 1 19 (CHECK ❑ C-57 Authorization for Other to Sign Permit ALL ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR THAT APPLY) ❑OVER -BORE DIAMETER of inches to depth of feet PRESSURE GROUT To depth of feet below surface ❑ . EXPLOSIVES From to feet below surface ❑ W LL PERMIT# MUSHROOM CAP Permit 3 feet below surface or feet below surface if >3 feet 1152 x Fl ❑ r that I am authorized to complete this application and that the work will be done in accordance Joaquin County Ordinance Codes and Standards, and all other applicable California laws. . Signed � Title/Company Print Name �/ Date Application Accepted By: Grout Inspection By/Dates: (/ Destruction Inspection By/Dates: Date Issued: I/Z0 i4 racnn rJIIC FA Name {�� is��t3E8 E. I-4azelto A�`rr//cn;je � Stacktoi; t" �- EHD 29-�f 08-0 II IIVrlllgllVll �T1 FA PE 29 V () WP Reviewed By Work Plan Date 1 19 57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS /_ Al4 t Vyjp W 1Unk � � S 7 r ra . WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE W LL PERMIT# IN 01DO Permit 3 1 1152 x C C,(Aj LIdon IV 1-17 � / °i u'��0� 02�o /L'( CGliornla 05?_05 � T 209 �68••34"?0 � t= 209 4^a4-0138 1 ?annNv.sjcettd.com 5,., Site Midg;3UonApplication Z