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'ov i'aot' 'j . 0- c° SAN J OAQ U I N Environmental Health Department 4A — COUNTY-- �`cac, -" Greotness grows here. 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. Cal Trans ROW-So side of Lafayette St,between CA St&American St City/State/Zip Phone Stockton CA 95203 209-948-3656 Cross Street CA&American Streets APN None Property owner` Cal Trans, District 10, Joe Valdez Phone 209-948-3656 Address 1976 E Dr. Marting Luther King Jr Blvd City/State/Zip Stockton,CA 95205 510-357-3677 C-57 Contractor ConeTec Drilling License# 1049248 Phone Address 820 Aladdin Avenue City/State/Zip San Leandro,CA 94577 ConsultanU ub-contractor Ground Zero Analysis, Inc. License# PG 5234-Raynold Kablanow Phone 209-522-4119 Address 1172 Kansas Avenue City/State/Zip Modesto,CA 95351 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bohngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 120 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NIA TYPE OF CASING []STEEL❑PVC ❑ OTHER ® SOIL BORING 12 19 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth. ❑ INJECTION(Air SDYoe.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED 4UGERS ❑HOSE H)PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? fes ®No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS Cement 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 THEME TYPE TO BE USED ❑AUGERS [I HOSE [I PIPE —1 MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that 1 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 t, Title/Company Regional Manager, ConeTec Print NameJohn Rogie Date_ 10-31-2019 DEPARTMENT USE ONLY Application Accepted By: ., Date Issued: Grout Inspection By/Dates: 2 Destruction Inspection By/Dates' Facility/Site Information FA Name FA Address O --C' �a I �" FAi! 0 D� N PR# �5 FAP WP Reviewed By !�1 / Work Plan Date �Z� 9 ❑C-57 ❑C-57 Authonzation for Other to Syn Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑tvFR COMMENTS/CONDITIONS: rep r� L`LL Vx �a�1 r JP Pub/tCgTf'�Y� p ® 'i �l WP TYPE PE SC FEE INFO AMT REMITTEDI CHECK# RECV'D BY I DATEWELL PERMIT# INVOICES Permit 152 x �7 j 0 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EHD 29-01 09-01-17 Site Mitigation Well Permit Application