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U'"'..c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> cq<<FOR�:P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.socehd.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 Airport Way City/State/Zip 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 City/State/Zip North Highlands,CA 95660 <br /> C-57 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 /> Consultant/Sub-Contractor ECM Consultants License# Phone <br /> Address 3525 Hyland Ave, Suite 200 City/State/Zip Costa Mesa, CA 92626 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 35'bas ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3.2 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING _�® PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOILBORING IDs SB-4, SB-5, SB-6 GROUT SPECIFICATIONS 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 ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> // San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 14I/� Title/Company Project Manager/ECM <br /> Print Name Chris Drabandt Date 7/7/2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: ii Pi o,= Date Issued: 7/1•J1j6 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address IFA# I 00j8Z91PR# Z6 29 <br /> FA PE WP Reviewed By I I Work Plan Date j c i Tv r Z-/le <br /> ❑C-57 C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement EfLead Agency Approval FR <br /> COMMENTS/CONDITIONS: /S2-_ -re-,-A�'c �,lpe -to ekz�(4ct i9c,'tla—) CeweiLtPoJT, <br /> SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan Z�o3 523' !,`39a ''390 d 07-525-9 <br /> Permit 29th 313 $130x 3 4,3y0 091 Z -71,/1� 51Z00752-5-9 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />