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FIV ; au'y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OCT 19 2015 - 1868 Hazelton Avenue, Stockton, CA 95205-6232 N'P.• Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sicehd.comIVVIERMI_N RAL HE PERM I t/SER1lICES 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 Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in,5omplignce with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address {0 3 0 S. C.E . D I X O N S T FL E E t' City/State/Zip S To C K To N, C A Phone (109) 983- 0 1 2 8 Cross Street LOCKHEED CDVRT APN I-}'}-260-3!' 9520rp Property Owner" 5TocKropy t-%EtRoPot,tTA% AIINFORT Phone C-.09)!68- 4+00 Address 5 0 0 0 S. A I R F O R T W A`( City/State/Zip S T O C K T O N ` CA 95206 C-57 Contractor \14 \r4 D R l L L 1 N G, (tic. License# C-S} 4 1109 0 4 Phone (10 9) 46 9-1100 Address 3 B 0 6 D V C h C R E E R DK I V E City/State/Zip s T o c its,t.o N 1 CA 9 5 2 1 5 ConsultantlSub-Contractor NAMAGE ENVIRONMENTAL, INCI-icense# P.G. S 856 Phone (.11s) 851-+ 9 Address F.0, Box 1,8353 City/State/Zip R E N 0 , N V $ 9 5 i 1 i I CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS t V A ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Saarae 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) i WELL/SOIL BORING IDs GROUT SPECIFICATIONS I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 6 [j OVER-BORE DIAMETER of '? inches to depth of 6 0-65(eek(ToTA L D E P TN S) WELL IDs MW-1, MW-1, MW-3, MW-14- MW-5 , MW-6 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS N E A T F 0 a T L AN D C E M E N T P EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED WAUGERS ❑HOSE ❑PIPE [:'MUSHROOM CAP [:i3 feet below surface or feet below surface if>3 feet COMMENTS: RAMArrE. 5-NvIRONMENtAL WORK PLAN, DATED TVNE 13111015 (ATTACHED) SND WORK PLAN APPROVAL L-V 17TER , DATED TUNE 30, 2015 ( ATTACHF-D) I hereby certify that I am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed " I ^'1 L— Title/Company CO Jk P, P NES. RA MA GL r-- KV., INC. Print Name TOS E P N R A M A Vi Date to (I(D its DEPARTMENT USE ONLY ! Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name I I FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Camp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTSICONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan � � ) %l� �'� ' � C' ) J�J �'I //�; lit �'/5 '� 3 PermitZ9 ) L5 O =, i; _ 7$130 x UC i I EHD 29-01 6-23-2015 Site Mitigation Well Permit Application