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SAN JOAQUIN COUNTY rr G1 ENVIRONMENTAL HEALTH DEPARTMENT �• •' 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:WWW.sicehd.com 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 1835 North Report Ave City/State/ZipStockton,CA 95205 Phone Cross Street Waterloo Rd. APN 143-140-26 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 Consultant/Sub-Contractor Rubik Environmental License# CA PG 8853 Phone (775)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 x❑ MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 65 Feet ❑BOLTED TRAFFIC BOX ®STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 6 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Schedule 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING x❑Yes ❑No Boring Dia: Casing Dia: 2 inches Casing Depth: 65 FPPt ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 43 Feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [K]PIPE ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? El Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs MW-27A&MW-28A GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED` DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 \ ® ER-8aRE DIAMETER of 8-10 inches to depth of 5 feet WELL IDs E-1,PM-1,&PM-2 x PRESSURE GROUT To depth of 65-80 feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE x❑PI !y r]WUSHROOM 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 �y Title/Company Regional Director / Cascade Drilling, L.P. Print Name Ralph McGahey Date April 21, 2017 DEPARTMENT USE ONLY 1 Application Accepted By: � Date Issued: 5 Grout Inspection By/Dates: ZAAVJ -L 1 in L b '- Destruction Inspection By/Dates: L -yC ip�r it IvIV 11 It 1 t:-1 L (o1-71f-1 Facilit /Site Information f C FA# c C PR# 1 FA Name �U JC +�y� �YL FA Address /(,),S ;� . '� . 'G��rJ Uel 7 / fyQ�. FA PE 2 f lJ WP Reviewed By Work Plan Date : C /1 7 E C-57 ❑C-57 Authorization for Other to Sign Permit D,Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement al-ead Agency Approval D MFR COMMENTS/CONDITIONS: /JA L / �!/ -Z j�,� �.Jt:. (�IGf—AJC►(�� )�a��n � r*�1. �� S��C/)'7 SR TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV-D BY DATE SERVICE REQUEST# INVOICE# Permit `)I ' $139 x Y .� ,: .Z' i'�l 7 1 L -)'-7 H EHD 29-01 10-26-2015 Site Mitigation Well Permit Application