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SAN J OA Q U I N Environmental Health Department :. COUNTY reotness 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 ReClL!i.Pd For All lnspect -:s 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 7 6 y �` �p 1,� �I��rdCky/State/Zlp Stockton,CA 95206 Phone (209)468-4709 Cross Street Arch Airport Road �( CA IRNA RY APN 17726034 Property Owner' County of San Joaquin Phone (209)468-4709 Address 5000 S Airport Way,Suite 202 City/State/Zip Stockton,CA 95206 C-57 Contactor License# Phone Enprobe,Inc. 1012248 (530)589-2019 Address P.O.Box 6093 City/State/Zip Oroviile,CA 95966 EnSafe,Inc. (925)305-2109 ConsukantlSub-Contactor License# 5014654 Phone Address 1355 Willow Way,Suite 120 City/State/Zip Concord,CA 94520 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 eet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERIORNEN DLA.OF BOREHOLE lac es ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 10 ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth. ❑ INJECTION(Air Soros.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) WELU SOIL BORING IDs SS-1 through SS-10 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 10 soil borings ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs SS-1 through SS-10 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat-cement grout from bottom of boring to surface ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS HOSE 91 PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: All 10 shallow soil borings will be destroyed with neat-cement grout using tremie pipe to fill from bottom of boring to surface, estimated boring depth of 5 feet. I hereby certify that I am authorized to complete this application and that the work will be done In accordance wkh uin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company CD'f' ? C� ✓ Print Na vuDate ' ZZ- D ARTMENT USE ONLY Application Accepted By: Date Issued: Z Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilltv/Sil e Inforrnation V FA Name 1 ) 40V FA Address S6oD 1 Iv FA# ZS PR# FA PE ?A1 D WP Reviewed By I V Work Plan Date �. p CIC-57 C 57 Aurhatzatlon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑AOCM Agreemanl ❑Lead Agency Approval ❑MFR COMMENTs/C NDITIONS: ft ' � Tzf W �r �-- n.,S WPTYPEJ PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE LL PERMIT* INVOICE# Permit �� 152 x C.0 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EMD 29-01 06-01-17 site Mitigation Wel Permit Apphcabon 59001 l43�