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c. SAN JOAQUIN COUNTY <br /> --�� -.off\ <br /> r Z` ENVIRONMENTAL HEALTH DEPARTMENT <br /> c �I <br /> •i 1868 Hazelton Avenue, Stockton, CA 95205-6232 www.sicehd.com <br /> 'i**� Telephone: (209)468-3420 Fax:(209) 468-3433 Web: ww.sicehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 8010 AirportWay City/Staterzip Stockton, CA 95206 Phone <br /> Cross Street Stimson Street APN <br /> Property Owner" California Army National Guard (LTC Belinda May) Phone 916-854-1483 <br /> Address 3900 Roseville Road cityfstateizip North Highlands,CA 95660 <br /> CS7 Contractor Penecore Drilling License# 906899 exp 11/30/17 Phone 530-661-3600 <br /> Address 220 N East Street City/State/Zip Woodland,CA 95776 <br /> ConsuhanUSub-Contractor ECM Consultants License# Phone _ <br /> Address 3525 Hyland Ave,Suite 200 City/State/Zip Costa Mesa,CA 92626 <br /> CONSTRUCTION WORT(TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MO4LTORING ❑ HOLLOW STEM BORING DEPTH 45 S ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> D EXTRACTION(VaporWateo ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER <br /> ❑SOL BORINGM PUSH POINT)GPI CPT) CONDUCTOR CASING ❑Yes ❑No BwN Oa: Casing Dia: Casing Depth: <br /> M INJECTION(A.s,,Omer,.) __23__❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE M PIPE <br /> ❑OTHER ❑ OTHER: GROUT SEAL PUMPED? M Yes ❑No (Ndw Mavmwn Freefa'I Depth is 30 Ft) <br /> WELL)SOIL BORING!Da 1-65 thratl,gh 1-87 GROUTSPEaFICA-now Bentonite 5%,Portland Cement 95% <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs_ ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE Ej PIPE ❑MUSHROOM CAP 3 feet below surface or feet below surface If>3 feet <br /> COMMENTS: <br /> 1 hereby owtlfy that 1 am wtttafzed to complete this aWlcation and that the wort velli be done In accordance with <br /> C Sen Joaquin County Ordira nce Codes and Standards,and other aWIcable Caglots <br /> rnia las . <br /> Signed �� Tde/Company Project Geologist! ECA1 <br /> Print Name Chris Drabandt Date 11/16/2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By %L� ��� Date Issued: <br /> Grout Inspection By/Dates: _ <br /> Destruction Inspection By/Dates: <br /> Facili Site Information <br /> FA Name FA Address FA# ( i`a'�L PRk t'5 2 7 V34- <br /> FA PE WP Reviewed By l t/G r �,J, Work Plan Date <br /> [3C-57 Q'C-57 kthorin4on for Other to Sign Permit p Worker's Camp ❑VVMes Camp Waiver ❑Entroardrrwt Permit ❑Aoaras Agme-meM 0 Lead Agency Apprcval d MFR <br /> COMMENTS/CONDMONS: (Tn.t bow,h�f !✓�4/t�o�r/swd�e�crGf,NcG as�ryp�siv/sa ffi�t>(°���wc� (a,ca-(c p/c�� <br /> I <br /> SR TYPE PE SC I FEE INFO AmT REMrrTEDj CHECKK I RECV'D BY DATE SERVICE REQUEST# INVOICES <br /> Work Plan 7�� .l 7/7 — I�52r)1 121411 W 741-f /I <br /> Permit 09o5 ;i j ,99x if-5L91 <br /> ,gym C>P <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />