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� . � � �� d �, � � nvironmental Health Depa- Srtment y COUNTY --- -- Enecs grows here.., SITE MITIGATION WELL ORING PERMIT APPLICATION for Wells and Borings Used for Contaminant Investigations and Remediati"on 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-ml 1 and the San Joaquin County Well Standards. Boa address 24427 South Chrisman Road C,ty�st aterzip Tracy , CA 94378 Phone cross street Cabe Road APN 250-1 60ml 1 Property Owner* Annette Eldi.s.sagaray Phone 11 0 . P Address 8140 West Valpico Road Colty/StatW21P Tracy, CA 95304 Cw57 Contractor PeneCore Drilling Luicense# 906899 exp . 11 /30/2021 phone 530m661 o-3600 Address 220 North East- Street Csity/State/Zlop Woodland , CA 95776 Consultant/Sub-Contractor Terracon Consultants Inc. Liocens phone 209-294m7O27 Address 902 Industr'lal Way City/State/Zip Lodi , CA 95240 CQNSIRU!;TION WORK TO BE PERFORMED., Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits k" TYPE .OF WELLIBORING NUMBER 4NSTALLATION TYPE CON. STRUCTION SPECIFICATIONS ❑ MONITORING HOLLOW STEM BORING DEPTH 5 to 15 and 1 to 59 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE Q EXTRACTION (Vapor/Water) HAMMERIDRVEN DIA. OF BOREHOLE 3" ❑ MULTIPLE CASINGS 1:1 MULTI-LEVEL WELL CASING DIA 0 SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC OTHER M SOIL BORING � ❑ PUSH POINT (GPI CPT) CONDUCTORCASING 0Yes0No '1BodngDia: Casing Dia: Casing Depth: p INJECTION LAk-spme, ozone p HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE US-ED: 0 AUGERS HOSE PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes El No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BOPJNG IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO 13E PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED OVER-BORE DIAMETER of 1 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 [I AUGERS ❑ HOSE ,,,,,[:] PIPE E:1 MUSHROOM CAP [:13 feet below surface or feet below surface if >3 feet COMMENTS: Borings to be drilled by a direct-push Geoprobe drilling rig. At the completion of drilling , the five 15-Afoot borings will be backfiffed using neat cement free-fall poured into the borings. The 50-foot boring will be b ckfill d using neat cement tremi ed into the boring using a PVC pipe,, I roby cerkity that 1 am authorized to compfet� this application and that the work -will l be done in accordance with San Joaquin County Oroinance Codes arc! Standards, and aR.- other applicable Califomma Taws. Signed Title/Company Environmental Department Manager / Terracon Consultants, Inc. Print Name i k pQ h Date Jan uary 7. 2021 0, 0 DEPARTMENT, USE ONLY Application Accepted By: Date Issued : Grout Inspection By/Dates: Destruction Inspection By/Dates: di Factlitv/Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date I.- f El C-57 [:1 G-57 Authorization for Other to Sign Permit n Workers Comp ❑ Worker's Comp Waiver ❑ Encmachment Permit ❑ Acces's 'Agreement El Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS : WP TYPE PE SC FEE INFO AMT REMITTED' ': ' CHEC K# RECV'D BY DATE WELL PERMIT# INVOICE# Permit : $152 x 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 � www.sjcehd -, com EHD 29-0108-01-17 Site mitigation Well Permit Application