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?°P4Ufh . SAN JOAQUIN COUNTY " E EIVE® a:. < ENVIRONMENTAL HEALTH DEPARTMENT SEP 23 2016 ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web. SEEN www.sicehd.com pERMITjgE��EAtTI{ 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 compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 5756 Pacific Avenue City/State/Zip Stockton Phone Cross Street West Robinhood Drive APN 102-27-10 Property Owner" Robinhood Plaza SC LLc 209-952-6297 Phone Address —1036 West Robinhood DriveSuite 2122 SP So �� City/State/Zip Stockton 9X107 Add Phone Contractor Sierra Tech.Services License# 959309 916-652-4040 Address City/State/Zip ConsultanttSub-Contractor Terraphase Engineering Inc License# Phone Address 2330E Bidwell Street#211 City/State/Zip Folsom,CA 95630 CONSTRUCTION WORK TO BE PERFORMED,*Note: Offsite BoringsAlVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 feet ®BOLTED TRAFFIC BOX ® EXTRACTION(Vapor/Water) EX-2.34 ❑ HAMMERrDRIVEN DIA.OF BOREHOLE ❑STOVE PIPE ❑ SOILVAPOR PROBE 4 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ MUD ROTARY CASING THICKNESS 2-in-diam,sched 40TYPE OF CASING: ❑STEEL 10 PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Nr Soame Ozonet ® HAND AUGER GROUT SEAL DEPTH 1.Sfeetto l0feel TREMIE TYPETOBE USED: ❑AUGERS ®HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note.Maximum Freefall Depth is 30 Fry WELL/SOIL BORING IDs EX-2,EX-3,EX4 GROUT SPECIFICATIONS 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 EX E - -4 = o ❑x PRESSURE GROUT To depth of 10 GROUT SPECIFICATIONS P feet below surface TREMIE TYPE TO BE USED ❑EXPLOSIVES From to_feet below surface ❑AUGERS x❑HOSE ❑PIPE /J—❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet 3 Wt-u5 �eB�n N.ccQ xy— �� I hereby certify that I aIn authorized to complete this application and that the work will be done in accordance with vvv��7 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed �,i Title/Company Principal Hydrogeologist,Terraphase Engineering, Inc. Print Name James Scott Seyfried P.G. Date 9/6/2016 DEPARTMENT USE ONLY Application Accepted By: /f/%ti �4�OA Date Issued: � �G Grout Inspection By/Dates: Okhl Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address FA# FA PE PR# WP Reviewed By /jr�E Work Plan Date 13 iT�t ❑C57 ❑G57 ulhorization for Other to Sin Permit 1 9 []Worker'sComp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement WLead Agency Approval FR COMMENTS/C (TIONS: ,)f O-rc WUIf }I r�µkyaQ : I II : 1 tpyc q. ar Cct,S r�Axj r 1 fo 1 �ac�er dtclo .� TG.. t r'4�-E �wg'7u is {eof" bs c�FPreSS�/e yru�7 exc4.vG.fc avro�,scl ftv5l.fco Cap rne..�Ce of B'T j1 e.5e t�eKrtt u.`♦•..ew t� 2fe�tf qr `ff C�-Jtny a+�Z.T SR TYPE PE SC FEE INFO AMT/REMITTED CHECK# RECV'D BY DATE SERVICE REQU/EST# INVOICE# Work Plan Z� 5 Z1 x/// I �"7/-� 119// �Y .371f 0Ar!o 0UZ Permit 2902 313 $130X 3 9y/7 //y0 6crl(. 590076003 -l�r , �G�PG4I fa�u// troll �'x FLmtyy� Y2aet-LIQ j/+�s' tack // r /tr'c✓f v/p. d'j; pe,;41 OurMc. l//i7/i4 eiNa"lc) Porn.�+ 1001184 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application