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SAN JOAQUIN COUNTY `y' � o.• c .� ENVIRONMENTAL HEALTH DEPARTMENT D za ( •' � 1868 Hazelton Avenue, Stockton, CA 95205-6232 2Q�1 �4�IFOR •; Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.socehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION �,cry For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 2222 & 2244 S. Airport Way City/State/Zip Stockton, CA 95202 Phone Cross Street E 9th Street APN 137-3(10-11 Property Owner* City of Stockton Phone 209-937-8309 Address 425 N EI Dorado Street City/State/Zip Stockton, CA, 95202 C-57 Contractor V&W Drillinct_ Inc License# C57-720904 Phone 209-469-7700 Address 3806 Duck Creek Drive City/State/Zip Stacktnn, CA 95215 Consultant/Sub-Contractor Condor Earth License# Jahn Lane, PG 6795 Phone 909-934-0518 Address __188 Frank West Circle, Suite I City/State/ZipStockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsPA'ells Require A ss greements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 f f 80LT TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 9 2,55" M IPLE CASINGS❑MULTI-LEVEL WELL CASING DIA W SOIL VAPOR PROBE 40 MUD ROTARY CASING THICKNESS 4. OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes o rin Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH MIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMP D? ❑Ye IW (No )mum Freefall Depth is 30 Ft) WELU SOIL BORING IDs SVP-1 through SVP-4 GROUTSPECIFICATI S DESTRUCTION WORK TO BE PERFORMED: DE T CTI CRT CHECK A/-THAT APPLY #WELLS TO BE DESTROYED ❑0 R- R DIAMETER of inches to depth of feet WELL IDs ❑ RE U GROUT To depth of feet below surface GROUT SPECIFICATIONS EXP L From to feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE ❑PIPE MUSH�OM P ❑3 fee surface or feet below surface if>3 feet COMMENTS: Soil Vapor Probes will be bored to a de hof 5' nd t e monitoring wells to 40'. SVP will have a borehole diameter of 2.25"and the holes will be filled in at the end of th da . I hereby certify that I am authorized q com le this application and that the work will be done in accordance with San Joaquin County Ordinance o as and Standards,and all other applicable Califgrnia laws. Signed Title/Company O) r ` T' t�4�,) Print Name Date f> 3t11-7 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# 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 COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV-D BY I DATE I SERVICE REQUEST# INVOICE# Permit $139 x EHD 29-01 10-26-2015 Site Mitigation Well Permit Application