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NOV 16 2017 Environmental Health Department SHAWN ENvfRONMENTN FALTIJ COUNTY 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. Job Address 14700 Schulte Road cltylstate2ip Tracy, CA 95377 Phone (209) 836-8269 Cross street S. Lammers Road APN 209-240-024 Property Owner^ Owens-Brockway Glass Container Inc. Phone (209) 836-8269 Address 14700 Schulte Road citylstate/zlp Tracy. CA 95377 C-57 contractor Gregg Drilling License# 485165 Phone (925)313-5800 Address 950 Howe Road City/Statelzip Martinez. CA 94553 Consultant/Sub-Contractor CKG Environmental, Inc. License# P.G 5077 Phone (707)363 5740 Address P.O. Box 246 citylstatelzip St. Helena, CA 94574 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BodngsliNells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [XMONITORING 1 CK HOLLOW STEM BORING DEPTH 85 feet a BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapuMater) ❑ HAMMER/DRIVEN DIA OF BOREHOLE 8-inch ❑MULTIPLE WINGS❑MULTI-LEVEL WELL CASING DIA 2-Inch ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sched 40 TYPE OF CASING: ❑STEEL IX PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING []Yes INo Boring Dia: Casing Dia: Casing Depth: EIINJECTION Ilk mese.oma [3HAND AUGER GROUT SEAL DEPTH 60 ft^ TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I$PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? IXYes [I No (Note,Maxim=Freefall Depth is 30 Fd WEWSOIL BORING IDs MW-5R GROUT SPECIFICATIONS Standard 16 sack mix With no more than 4% bentonite DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_Inches to depth of feet WELLIDs ❑PRESSURE GROUT To depth of_feetbelowsudace GROUT SPECIFICATIONS ____ ❑EXPLOSIVES From—lo—feet below surface TREMIE TYPE TO BE USED AUGERS ❑HOSE PIPE __ MUSHROOM CAP Ej 3 feet below surface or feet below surface IT>3 feet COMMENTS: I hereby certify that I am authorized to completo thls application and that the work will be done In accordance with ,ft JgaquIn County Ordinance Codes and Standards,and all other applicable California laws. Signed, j,I ', _- •• Title/Company CKG Environmental, Inc. Print Name Christina Kennedy Date 10/24/17 DEPARTMENT LY �7 Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Fa IiInformation FA Name O"'J� �d�e "`"�. FA Address t�-�00 .n J FA# �0�� PR# FA PE b� WP Reviewed By �/ W� Work Plan Dale `��3 I t.3 ❑C-57 G57AugwdaatlonforOttwoSign Permg 4KprkersComp ❑Workers Comp WaNer ❑Enaoachmenl Permit ❑Aaess Agreement Lead Agency Approval 9KFR COMMENTSICONDITIONS: yyY.y W � - 0•y-� JVIPTYPEJ PE I SC I FEE INFO JAMT REMITTED1 CHECK#I RECV''D BY I DATE I WELL PERMIT# INVOICE# Permit Ze14 1 j3j152x I -- 133(a D I L-X I i-t.•lS 17 W u 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHDN-01 06-01-17 Site Mitigation Well PamYt Application w f aw 823 t�2 X i tq�j, 3sal t �( tt�IS�t1 sfao-165v