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I 'ECEIV D �o�Qa . oG SAN JOAQUIN COUNTY APR ENVIRONMENTAL HEALTH DEPARTMENT 6 2017 ` ENVIRONMENTAL H •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 HEALTH �` P• hiTelephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com PERMIT/SERVICIES 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 1905 North Broadway Ave City/State/ZipStockton,CA 95205 Phone Cross Street Waterloo Rd. APN 143-150-04 Property Owner' Crop Production Services Phone 209-547-2600 Address 1905 North Broadway Ave City/State/Zip Stockton,CA 95201 C-57 Contractor Cascade Drilling,L.P. License# 938110 Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip West Sacramento,CA 95691 Cons ultanVSub-Contractor Rubik Environmental License# CA PG 8853 Phone ( 75)622-0857 Address 320 Flint Street City/State/Zip Reno, Nevada 89502 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p MONITORING 3 ❑ HOLLOW STEM BORING DEPTH 65 Feet x❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2in(borings)6in(wells)EI MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sch 40(wells) TYPE OF CASING: ❑STEEL ❑x PVC ❑ OTHER ® SOIL BORING 16 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes El No Boring Dia:2 in(borings) Casing Dia: 2 in(wells) Casing Depth: 65 It(wells) ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 65 ft(boring)43 n(wells)TREMIE TYPE TO BE USED: E AUGERS ❑HOSE x❑ PIPE ❑ OTHER © OTHER:_Sonic Wells) GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs Baring IDs IW-1 through IW-16 GROUT SPECIFICATIONS Well IDs MW-25A.MW-26A,and MW-29A 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: 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 Regional Director/Cascade Drilling, L.P. Print Name Ralph McGahey Date April 21, 2017 DEPARTMENT USE ONLY Application Accepted By: ('� D to Issued: �/�0 /1 Grout Inspection By/Dates: S iJ 7 ` V A — J fel-1 to Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address 'C a FA# i L PR# 07 FA PE G�� 0 WP Reviewed By FWorkPlan Date I C-57 [1 C-57 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ©Lead Agency Approval 0�1FR COMMENTS/CONDITIONS: SR TYPE PE l SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit )I $139x Z�l 7 � CC\ i7L 2,`/03AL3 ;y f `1 .L ' c,o 7'7/ z EHD 29-01 10-26-2015 Site Mitigation Well Permit Application