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SANJOAQUIN <br />11 :141. ) COUNTY <br />/ <br />Greritnecs grows here. <br />Environmental Health Department <br />RECE WED <br />' <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION ENvI R00:mEGN9T:ti'7 , EA .. i For Wells and Borings Used for Contaminant Investigations and Remediation 1 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH 48 Hours Advance Notice Required For All Inspections PERMIT/SERVICES <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 520 North El Dorado Street City/State/Zip Stockton, CA 95202 Phone <br />Cross Street E Oak and El Dorado St APN 139-060-32 <br />Phone 916 417 6858 <br />Tarvinder K. Bains, Trustee of the Tarvinder K Banks <br />Property Owner* Revocable Living Trust Oct 22, 2017 <br />Address 6111 Turnbury Ct City/State/Zip Dublin CA 94568 <br />916 417 6858 C-57 Contractor Environmental Control Associates, Inc License# C95970 Phone <br />Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 <br />714 717 1037 Consultant/Sub-Contractor Terrax Environmental, Inc License# #97276) Phone <br />Address 16541 Gothard Street,#111 City/State/Zip Huntington Beach CA 92647 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> <br />TYPE OF INELUBORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparse, Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br />HAMMER/DRIVEN DIA. OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING <br />HAND AUGER GROUT SEAL DEPTH <br />OTHER: <br />0 BOLTED 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 />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED Five wells <br />WELL IDs B-1 B-2 B-3 B-4 and B-6 <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED Z AUGERS HOSE PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />DIAMETER of 6- inches to depth of 15ft <br />Z OVER-BORE <br /> <br />feet <br />PRESSURE GROUT To depth of feet below surface <br />Z EXPLOSIVES <br /> <br />From to feet below surface <br />EI MUSHROOM CAP <br /> <br />3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <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 />Title/Company Environmental Control Associates <br />Print NameTim Tyler <br /> <br />Date September 26, 2016 <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: lo/ 7,v) 1 is 1. Ick5 e.4 01, 13c <br />Facility/S itenformation - • A ,s ciaeej <br />FA Name V6_...e..4.-- <br />J <br />FA Address <br />I <br />5-ZA2 L) : •c, • t..4 lc -':••*.- FA# 0 0 .7.,44 • 2V-I PR# -f I, • <br />FA PE ci.'cu, WP Reviewed By L. _ X Work Plan Date 9 ,'ti- , <br />0 0-57 Ga-C17 Authorization for Other to Sign Permit 10i/ulcer's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 01OR <br />COMMENTS/CONDITIONS: <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 <br />k<-) <br />I. <br />/ I <br />aj (itiret.AN Pt