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FILL;r.1 V Mj JUL 0ORIGINAL SAN JOAQUIN COUNTY E�NNVIRONMENTAL HEALTH ENVIRONMENTAL HEALTH DEPART NfEf�,-�RMITISERVIGES LOP " SITE MITIGATION \'•, 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV q�� o;.�;;P• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siQov.ora/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Standards of the San Joaquin County Environmental Health Department. Site Location 8010 S.Airport Way Cross Street Stimson Street City/State Stockton,CA Zip 95206 APN 17726004 Owner CA Artrrpldatfdttal retard STY*Te. Address 10260 Mather Blvd. City/State Mather,CA Zip 95655 Phone 916-369-4375 Y C-57 Contractor Penecore Drilling Address 220 N.East Street Cit /State Woodland,CALic 0906899 Phone 530-681-3600 Consultant/Sub Cntr ECM,Inc. Address 3525 Hyland Ave.,Suite 200 City/StateCosta Mesa,CALic #778024 Phone 714-662-2759 Billable Party CA Army National Guard Address 10260 Mather Blvd. City/State Mather,CA Zip 95655 Phone 916-369-4375 GIS Coordinates:X -121.247 Y 37.8848 _17 , 71/ CONSTRUCTION WO K 0 BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ®OTHER IDS 36-direct push injection points which will be installed in 2 mobilizations,18-borings during week of 7/14/14 and 18-borings during week of 8111114 TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS '- TYPE OF CASING. ❑STEEL ®PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 36®INJECTION(i.e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Boreholes will be abandoned with neat cement after completion of injections _❑OTHER: ❑OTHER: APPROX BORING DEPTH 45 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing DepthBoring Dia: COMMENTS: 36-direct push injection points Cur ISCO injections. Boreholes will be abandoned per S(EI ID regulations upon completion of injections NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applicable California laws. p Signed �� Title/Company project Manager-Sc Geologist/ECM,Inc. 9 7/1/2014 Print Name Luis Mercado Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESSR01 I fR Pa2T' W�h ST�KT WORK PLAN DATED .I LL9.1 Z) 2,0 r I APPLICATION ACCEPTED BY J 4 DIA'KL/m _ DATE I ! AA GROUT INSPECTION BY FINAL INSPECTION BY k DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR#. CfO� $125x 1 ( C��ct.y 7-3-/ SR# 7v Ce-)8 375' (335oo PR# 2900 C-57 WC f/ WAIVER Alf�,= C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP