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SAN JOAQUIN COUNTY � ''1V k` rr z ENVIRONMENTAL HEALTH DEPARTMENT a <� NOV 1 1 2016 `• / 1868 Hazelton Avenue, Stockton, CA 95205-6232 EI�VIR� �l`�,RN' ' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sucehd.com taIEN'1AL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICATION ERNi1TISERWCES 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 8010 SOUTH AIRPORT WAY City/State/Zip STOCKTON, CA 95206 Phone Cross street STIMSON RUAU APN 177-260-04 Property Owner*CALIFORNIA ARMY NATIONAL GUARD Phone Address 8020 SOU I H AIRPOR t WAY City/State/Zip STOCKTON,CA 95206 C-57 Contractor CASCADE DRILLING LP License# 938110 Phone 916-638-1169 Ext 2331 Address 3000 Duluth Si, City/State/Zip West Sacramento CA 95691 ConsultanUSub-Contractor ENDPOINT CONSULTING License# Phone 415.706.8935 Address 1534 PLAZA LANE#243 City/State/Zip BURLINGAME,CA 94010 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Bonngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING 8 HOLLOW STEM BORING DEPTH 35 FEET ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 INCH ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth. ❑ INJECTION(Air Sparge,Ozorel ❑ HAND AUGER GROUT SEAL DEPTH 15 FEET TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fl)�— �( WELL/SOIL BORING IDs SB-4,SB-5.SB-6 GROUT SPECIFICATIONS 5 sack mix f G 'f(«roc (E ucLk+ h e T 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:We are going to take samples at 17,22,27,32 feet below grade.After reaching the 35 feet depth,the augers will be removed. The bore hole will then be backfill to the surface with 5 sack mix,and top off as need.The last foot will be completed with rapid set concrete and dyed to match existing surface. I hereby certify that 1 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. rM+M*5^'a M Smn Pohm Signed u° °^ °' Title/Company ENDPOINT CONSULTING INC. Print Name SCOTT POLSTON Date 11/14/16 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: �rJl) /') -Z t f'Y? Nr✓1� i"/7114 L--�k) y 17 1'/ /G Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By / G Work Plan Date J tit ZU r 7 OC-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workefs Comp Waiver []Encroachment Permit ❑Access Agreement [3 Lead Agency Approval ❑MFR COMMENS/CONDITIONS: P w/"pc,-r Icw'c, .T yi CX SR TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE SERVICE REQUEST# INVOICE# Permit 290j ,13 $139x 3 Yy� l 753) Use 290 3 j 543 5,2 00 700 Sy �r idd�orwrl �EoKC. EHD 29-01 10-26-2015 Site Mitigation Well Permit Application Sk0L) 766955