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RECEIVED SAN JOAQUIN COUNTY `-+ ENVIRONMENTAL HEALTH DEPARTMENT JUN 13 209 1868 Hazelton Avenue, Stockton, CA 95205-6232 c`q. Telephone: ( � � / ENMRONWNTALHEALTH Telerl209 468-3420 Fax: 2091 468-3433 Web:www.sicehd.colilo-Wrr/$ ES \C%F,pRd 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 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 1819 S. Argonaut St. City/State/Zip Stockton, CA 95206 Phone None Cross Street Irene APN 16320008 Property Owner" John Taylor Fertilizer c/o Eric Jenks Phone 510-236-6282 Address PO Box 511 City/State/Zip Yuba City, CA 95991 C-57 Contractor Gregg Drilling and Testing License# 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor Geosyntec Consultants, Inc. License# NA Phone 916-637-8341 Address 3043 Gold Canal Dr Suite 100 City/State/Zip Rancho Cordova, CA 95670 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS IX MONITORING a(MWS)❑ HOLLOW STEM BORING DEPTH Shallow-30',Deep-90'IX BOLTED TRAFFIC BOX ❑STOVE PIPE IX EXTRACTION(Vapor/Water) i(EWS) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE Greater than e" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS No casing TYPE OF CASING: lK STEEL®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ($No Boring Dia: Casing Dia: Casing Depth: 229 INJECTION(Air Soarae,ozone) (Iws)❑ HAND AUGER GROUT SEAL DEPTH shallow-te',Deep-60TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IN PIPE ❑ OTHER C& OTHER: Itosonic GROUT SEAL PUMPED? M Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs Monitoring Wells MW-e,-C,-D,-E,-F,-G GROUT SPECIFICATIONS Grout Dumped into tremie pipe inserted to top of well installation. Injection Wells IW-B,-C,-D,-E,and-F Extraction wells EW-A and EW-B DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #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: MWs and Iws are 2"diameter wells.EWs are 4"diameter wells. All wells installed with a minimum 2"radius between well and borehole wall. I hereby certify that I 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. Signed �� ' Title/Company Hydrogeologist,Geosyntec Consultants Print Name CA PG#9377 Date 6/13/2017 DEPARTMENT USE ONLY i Application Accepted By: * Date Issued: Grout Inspection By/Dates: Z3 / ') !'o c7 /'7 Destruction Inspection By/Dates: Facili /Site Information J tw ► FAAddress Lq FFA# PR# vFA Name Oe FCq I SOS?'13 FA PE 2-0�(oO WP Reviewed By L _ x Work Plan Date Z I `,✓ ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO All REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit 'ZCtp1 31'3 $139x 5- T r(j5- to CW L_ ko/ L`7�1"1 S fZOt).'i"1"7`7 1 ,NP V:W3 323 133 1-1 l011 L 5f-00-1-1-1l0 EHD 29-01 10-26-2015 Site Mitigation Well Permit Application