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C � c SANPJ0A0UIN Environmental Health Department —COUNTY— Greatness Greatness 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 1�6B' -03. 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. Shoulder area N side of Lafayette St,between CA St&American St Job Address City/State/ZipStockton, CA 95203 phone 209-937-8349 Cross Street CA&American Streets APN None Property Owner' City of Stockton-Public Works-Antonio Pinillos Phone 209-937-8349 Address 343 N EI Dorado St City/State/Zip Stockton,CA 95202 C-57 Contractor Cascade Drilling License# 93810 Phone 925-849-6970 Address 1641 Challenge Drive City/State/Zip Concord,CA 94520 Consultant/ 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 Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING 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 ❑MULTI PLIFCASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF,CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 16 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes IN No Boring Dia: �isW ing Dia: Casing Depth: ❑ INJECTION(Air Sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREYIE TYPE T B S D: AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 19 Yes ❑No (Note:Maximum F of th Ft) WELL]SOIL BORING IDs GROUT SPECIFICATIONS Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METRO HEVTHAA #WELLS TO BE DESTROYED ❑OVER-BORE TERth of :IV WELL IDs ❑PRESSURE GROUT o depth ofceGROUT SPECIFICATIONS I�EXPLOSIVES From surfaceTREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE El MUSHROO 3 feet bef t to3 feet COMMENTS: ,�/ I 11 �� 0 Il I hereby certify that I am authorized to comp) e t appllcation n th he o k III be done In acc r a ce with San Joaquin County Ordinance C des a tandard an o r p licable California to Signed Title/Co p y Print Name Date DEPARIMENT USE ONLY I Application Accepted By: D Is d: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address A FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authoriz ' n for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDI ' J WP TYPEP SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit $152 x I I I I 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application K100 ?V