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SAN JOAQUI <br />Eaivironmental Health Department <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 O _ _ � <br />�r?i i'nCT.tYa riCiVF.r.€"1 i;E� (� s3t:f(:ts. R` -o uiv d lr"OA All Inspf:cit" is b 33� <br />Application is hereby made to San Joaquin County for a permit to construct Al <br />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 />b Add2502 Dorset Lane <br />CitylStatep Tracy, CA 95377 Phone RabMoniz(Arcadis)e25798-73 <br />Joress <br />77 <br />cross street BlaCkblyd Court APN 238-300-08 <br />Property Owner* Mr. Heredia Phone <br />Addn <br />C-57 <br />Address <br />2502 Dorset Lane City/State/Zip Tracy, CA 95377 <br />tract Peneeore � G A Pri � �� License# 906899 Phone <br />220 N. East Street City/State/Zip Woodland CA 95776 <br />Consultant/Sub-Contractor Rob Moniz - Arcadis License# Phone <br />Address 2300 Clayton Rd, Suite 400 <br />City/StatelZip <br />Concord CA 94520 <br />(530)661-3600 <br />925.788.7377 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING OF.PTH 10 ft ❑ 80LTE0 TRAFFIC BOX ❑ S70VE PIPE <br />❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 3,5 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />X SOIL VAPOR PROBE MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC X OTHER Teflon tubinq <br />❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes Pq No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (A4 Soaroe Ozone) HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes D( No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs B-13 GROUT SPECIFICATIONS Hydrated Bentonite Grout 1' to 4'9" in <br />DESTRUCTION WORK TO RE PERFORMED <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ P <br />COMMENTS: <br />Signed _ <br />Print Name <br />By: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑OVER -BORE DIAMETER of inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />rl MUSHROOM CAP El3 feet below surface or feet below surface if >3 <br />certify that 1 am authorized to complete this application and that the work wiN be done in accordance <br />San Joaquin County Ordinance Codes and Standards -,and all other applicable California laws. <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Title/Company "4e J — <br />Date �� / I <br />Date Issued: <br />racutt tsae <br />1 ��^8 �+N�eltotT Avenue ( btCcktan, Ca!i�r�rrra 95205 f s 20941, '? j t= 209 46.4-0'135 14vvvw.s�eena.com <br />�Mitigation W eil Permit <br />Site ili� <br />er 1 2 ��1 17 <br />/ <br />` <br />M,47 � <br />� � � <br />Inrormauon <br />FA Name <br />FA PE <br />L% <br />WP Reviewed By <br />Work Plan Date <br />A <br />C-57 <br />C] C-57 Authorization for <br />Other to Sign Permit <br />❑ Worker's Comp El Worker's Comp <br />Waiver ❑ Encroachment Permit E]Access <br />Agreement ❑ lea <br />an y Approval ❑ MFR <br />COM EN <br />S/CONDITIONS: <br />7/ J <br />, <br />�,.� n Jj <br />YAI� W/7 <br />1) A <br />N <br />t <br />�I <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT <br />INVOICE# <br />Permit <br />2jI 3 <br />$152 <br />x <br />Z <br />e w <br />V V ?DO `0 <br />rye <br />Q <br />� A�ication <br />L <br />