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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 HazeIton 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 1101 Holly Drive City/State/Zip Tracy, CA, 95376 Phone (800) 511-9300 Cross Street East 11th Street APN 233-120-13 Property Owner" Willoughby (Web) T. Jordan Phone (209) 914-0734 Address 1435 Montrose Drive City/State/Zip San Leandro, CA, 94577 C-57 Contractor Advanced GeoEnvironmental, Inc (AGE) License# 680227 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 Consultant/Sub-Contractor AGE License# 680227 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE MONITORING 0 HOLLOW STEM EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN SOIL VAPOR PROBE CI MUD ROTARY 13 SOIL BORING 2 0 PUSH POINT (GP/ CPT) INJECTION (Air Sparse. °zonal 0 HAND AUGER 00THER WELL/ SOIL BORING IDs DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS D HOSE 0 PIPE CONSTRUCTION SPECIFICATIONS BORING DEPTH 20-40' DIA. OF BOREHOLE 1.5" CASING THICKNESS CONDUCTOR CASING w i Yes 3 No 4' GROUT SEAL DEPTH r0 0 BOLTED TRAFFIC BOX 0 STOVE PIPE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA NA TYPE OF CASING: 0 STEEL 1:1 PVC 0 OTHER Boring DIa: NA Casing Dia: NA Casing Depth: NA TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE El PIPE CI OTHER: 61 f GROUT SEAL PUMPED? 1:1 Yes El No (Note: Maximum Freefall Depth Is 30 Ft) GROUT SPECIFICATIONS Potland Type 1/11 5-6 gallons water per 94Ib DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 0 OVER-BORE DIAMETER of inches to depth of feet PRESSURE GROUT To depth of feet below surface El EXPLOSIVES From to feet below surface 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet COMMENTS: See Preliminary Site Assessment Work Plan, dated 02 January 2015 and CVRWQCB Approval letter dated 29 July 2016 (GeoTracker). Access agreement attached I hereby certify that I am authorized to complete this application and that the work will be done in accordance with S / an:Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed 1,,...._„ 4/___ Title/Company Project Geologist / AGE Print Name Brian Millman I Date 19 April 2017 DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Date Issued .e/( ,61 /c-1 /_C-1 FA Name A t \-1-4(Lu4.___— FA Address — z , F / / - ...4- FA# 6) c. z $4 PR# 4`..)1"/ V/ 7 FA PE . Z--96 0 WP Reviewed By /4' Work Plan Date 1/ 0 C-57 0 C-57 Authorization for Other to Sign Permit 1:1 Worker's Comp 0 Workers Comp Waiver 0 Eperoachment Permit , . 0 's Access Agreement 0 Lead Agency Approval E -z MFR COMMENTS/CONDITIONS: g0 l"PPLAS I 114 cL i —'-(1 cec l C' _ ji SR TYPE PE SC FE INFO AMT REMITTED CHECK# RECV'D BY DATE . SERVICE REQUEST# INVOICE# Permit '`' , . , .,., , ), cl i $139 x ,.. : / ) ., • c c' - ,.- ) 3 J ,, 11 06117 Va. 7. 7 3 / Site Mitigation Well Permit Application EHD 29-01 10-26-2015