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SAN 10AQUIN Environmental Health Department COUNTY SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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 9999 S Austin Rd City/State/Zip Manteca,CA 95336 Phone 209-601-2274 Cross Street Lynch Rd APN 20106001,20106002,20106005,20106003 Property Owner* Osvaldo Cordaro,Environmental Manager Phone 209-601-2274 Address 9999 South Austin Road City/State/Zip Manteca,CA 95336 C-57 Contractor Pencore Drilling License# 906899 Phone 530-661-3600 Address 220 North East Street City/State/Zip Woodland,CA 95776 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 40n DPT,3711 SVE ❑BOLTED TRAFFIC BOX ®STOVE PIPE la EXTRACTION(Vapor/Water) 1 ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2"DPT,12•SVE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 4"PVC TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ® SOIL BORING 5 9 PUSH POINT(GPI CPT) CONDUCTOR CASING [:]Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaroe.Ozone) ❑ 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 DPE-1 through DPE-5 GROUT SPECIFICATIONS Neat cement SVE-11(well) DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDS ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed L Title/Company Professional,Geosyntec Consultants Print Name Katherine Clark Date 4,27?26 DEPARTMENT USE ONLY Application Accepted By: "t Date Issued:$h5be Grout Inspection By/Dates: Destruction Inspection By/Dates: .,t Ly 15, ,2 01 L .1 A6114C.14a v Facilit /Site Information Ul Zd FA Name FA Address FA# SAE JOAQ Inc' U1V ry PT n r'1.= A L FA PE WP Reviewed By Work an4a� ARTt��ENT ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Pe mit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: DVT -3 v4&,c b¢tEDc3> OYE1Z To iKoTA.LL. 314 r--II WP TYPE PE SC FEE INFO AMT REMITTED CHECK# REC Y DATE WEELJLPERMIT# INVOICE# Permit HH71 l x 1 20101 r-1 !� fn 1 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OB-01-17 Site Mitigation Well Permit Application