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SA N J OA Q U I N Environmental Health Department COU NTY --- 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 2135 S.Airport Way City/State/Zip Stockton, CA 95206 Phone None Cross Street E. 8th Street APN 169-077-030-000 Property Owner` City of Stockton Phone (209) 937-8862 Address 400 E. Main Street,4th Floor City/State/Zip Stockton, CA 95202 C-57 Contractor BC2 Environmental License# 969 758 Phone (714) 744-2990 Address 1150 West Trenton Avenue City/State/Zip Orange, CA 92867 Consultant/Sub-Contractor Weston Solutions, Inc. License# A HAZ 522739 Phone (541)593-3800 Address 2300 Clayton Road, Suite 900 City/State/Zip Concord,CA 94520 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 20 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ® OTHER 1/4"Teflon Tubing ISI SOIL BORING 3 IN PUSH POINT[GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia Casing Dia: Casing Depth: ❑ INJECTION(Air Sms,ozom ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ($I No (Note:Maximum Freefall Depth is 30 Ft) WELUSOIL BORING IDs SV Borings=V-1 through V-5 GROUT SPECIFICATIONS Soil Borings=B-1 through B-3 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: I hereby certify that I am allthorized to complete this application and that the work will be done In accordance with SayJoapuin o ty Ordinance Codes and Standards,and all other applicable California laws. Signed �t� Title/Company c�jQ fetS�'¢�m6iz— LW—C—N✓ Print Name 5; V1rl Date PARTMENT USE ONLY Application Accepted By: Date Issued: 2 Grout Inspection By/Dates: Lt Destruction Inspection By/Dates: Facili /Site Information FA Name a,�� NrOWh S FA Address 1357 S• hw l& V-1� I FA# Ot7Zs►� PR# OSy 2.1 FA PE vY WP Reviewed By Work Plan Date f -to I g' 57 ❑C-57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit Access Agreement ❑Lead Agency Approval OaxrR COMMENTS/CONDITIONS:LAJ0444, q ,9v4TlI-e P-9h.-� �.vy. v, Graf bit ..l�t �c, ov�r..6�rt i v 3""� �--STT d--t pi^^ �^-� ro.Kt -FQ►•^^ �+u WP TYPE PE I SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# Permit W5 1 313 $152. 3 LtS�6 Tggq iy 3 r,JQU0.3 _it 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application WIF tA03 SL3 tSZ X 7 � q% 'Ff44$T �� 3I�IM s"I g02