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SAN J 0 A Q U I N Environmental Health Department °° COUNTY • „g GreotnPss grows her 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 8610 S.Newcastle Road City/State/zip Stockton,CA 95215 Phone 209.235.9622 Cross Street Arch Road APN 201-060-010-000 Property Owner` Republic Services,Forward Inc.&Austin Road Landfills Phone 209.235.9622 Address 9999 S.Austin Road City/State/Zip Manteca,CA 95336 C-57 Contractor Cascade Drilling.LP License# 938110 Phone 707.639.7709 Address 3000 Duluth City/State2ip West Sacramento Consultant/Sub-Contractor Arcadis,U.S..Inc. License# Phone 805-7062805 Address 735 Tank Farm Road,Suite 150 City/State/Zip San Luis Obispo,CA 93401 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 125 feet ❑BOLTED TRAFFIC BOX El STOVE PIPE ® EXTRACTION(Vapor/Water) 1 ® HAMMER/DRIVEN DIA.OF BOREHOLE 12 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 8 inch ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Son.80 TYPE OF CASING: EI STEEL ®PVC ❑ OTHER Screen Steel.riser PVC ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes El No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air surae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE W❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ESI Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) ELU SOIL BORING IDs EW-5 GROUT SPECIFICATIONS Neat 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 TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed – — — " ' Title/Company . Cascade Drilling Print Name Rick Alcartado Date 7-31-19 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# FPR#T FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMM ENTS/CONDITIONS: WP TYPE PE SC I FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Site Mitigation Well Permit Application