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SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />G ,entnes , an,vvc here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIWEIVED <br />For Wells and Borings Used for Contaminant Investigations and RemediatiojAM II 26 2018 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections ENV„/RONMENTA , „ <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describrdE. RA4n7S "EALTH ER Vicpc <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standard? <br />Job Address 3437 South Airport Way city/state/zip Stockton, CA 95206 Phone <br />Cross Street Carpenter Road APN 177-02-33 <br />Property Owner* Applied Aerospace Structures Corporation Phone 209-983-3339 <br />Address 3437 South Airport Way City/State/Zip Stockton, CA 95206 <br />C-57 Contractor AECOM License# 769167 <br />Address 2020 L Street, Suite 400 city/state/zip Sacramento, CA 95811 <br />Consultant/Sub-Contractor License# <br />Address City/State/Zip <br />Phone 916-414-5800 <br />Phone <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: Well Alteration/Modification to existing monitoring well. No new well construction being performed. <br />TYPE OF WELL/BORING <br />X MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MW-2 0 HOLLOW STEM BORING DEPTH <br /> o HAMMER/DRIVEN DIA. OF BOREHOLE <br />0 MUD ROTARY CASING THICKNESS <br />RBOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />INJECTION (Air Spare& Ozone) 12 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELU SOIL BORING IDs MW-2 (Well Alteration/Modification) GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: *Work will involve alteration/modification to an existing well (MW-2). Surface completion of well will be <br />changed from above ground (stove pipe) to below grade (flush mount). <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 rd."4‘44'. Title/Company Project Manager/AECOM <br />Print Name Yuanyuan Andren (Attorney-in-Fact for Gardena Holding Inc.)Date 1/25/2018 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br /> <br />CL Date Issued: 2 / <br /> <br />Grout Inspection By/Dates: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Nat- <br /> <br />FA Name <br />, <br />pr ef 1 %.cit, ,.r911-zgfiathe, Address .---i 3 .1 < • 1 FA# CI CA. ri PR# cs- zci i,c12_. <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit .A,ot I -7, 3 7 $152x i S. ) .1 Oot; i .> L. A -2/sh,,,, w et:L.-31,13 1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application