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" SAN JOAQUIN COUNTY <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 QCOT 14 2016 <br /> ..c' P.. Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.sicehd.com <br /> ENVIRONMENTAL HEALTH <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMIT/SERVICES <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 SOUTH AIRPORT WAY City/State/Zip STOCKTON, CA 95206 Phone <br /> Cross Street STIMSON ROAD APN 177-260-29 17TZ(p61i F— f--­*-r..- +(-Y p44,ce.( <br /> Property OwneP CALIFORNIA ARMY NATIONAL GUARD Phone <br /> Address 8010 SOUTH AIRPORT WAY City/State/Zip STOCKTON,CA 95206 <br /> C-57 Contractor CASCADE DRILLING LP License# 938110 Phone 916-638-1169 Ext 2331 <br /> Address 3000 Duluth St, City/State/Zip West Sacramento CA 95691 <br /> ConsultanVSub-Contractor ENDPOINT CONSULTING License# Phone 415.706.8935 <br /> Address 1534 PLAZA LANE#243 City/State/Zip BURLINGAME,CA 94010 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ® HOLLOW STEM BORING DEPTH 35 FEET ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ® EXTRACTION(Vapor/Water) 6 ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 INCH ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCH 40 TYPE OF CASING: N STEEL ®PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ® INJECTION(Air Soarae.Ozom 6 ❑ HAND AUGER GROUT SEAL DEPTH 15 FEET TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING IDs IW-1,IW-2,IW-3,IW-4,IW-5,IW-6 GROUT SPECIFICATIONS HIGH TEMP RESISTANT GROUT"SEE ATTACKED MSDS" <br /> EW-1,EW-2,EW-3,EW4,EW-5,EW-6 <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 ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> THE STEAM INJECTION WELL(IW-1 TO IW-6)WILL USE STAINLESS STEEL CASINGS,WHILE THE EXTRACTION WELLS(EW-1,TO EW-6)WILL USE PVC CASING <br /> .4(herelly ify th It I am authorized to complete this application and that the work will be done in accordance with <br /> quin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed !L° -""°""""° " Title/Company ENDPOINT CONSULTING iNC. <br /> Print Name SCOTT POLSTON Date 10/10/16 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: //y1�0 7� ldf2T�/6; -4- <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information Q <br /> FA Name FA Address [�,/ FA# �� p Z�/� PF4 b y ►3&i <br /> FA PE WP Reviewed By �vG// '�^r!/�i� Work Plan Date <br /> ❑C-57 Eff57 Authorization for Other to Sign Permit Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement �ead Agency Approval FR <br /> COMMENTS/CONDITIONS: l/SG &fHCgI, 4-e-,AWev4*",,e- yr�"w'r a0pjV--e <br /> SR TYPE PE I SC I FEE INFO JAMT REMITTED1 CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Permit 2901 3l 3 $139 x 5 �q� 7��� C.�r� Y9,00 A�0 55 <br /> 2903 523 ,//7 �/7 7537 �vz'� -5Ro0746S`f <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />