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SAN J O A Q U I N Environmental Health W&OAURD %/RD , .-•- pFRFN� SITE MITIGATION WELL 8t BORING PERMIT APPLICATION S For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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 1744 West Hammer Lane City/State2ip Stockton, CA 95209 Phone Cross Street Brentwood Drive APN 077-280-32 Property Owner' Sims-Grupe Management Corporation, Inc Phone (209) 478 9200 Address 374 Lincoln Center City/State/Zip Stockton, CA 95207 C-57 Contractor J&H Drilling Co., Inc. License# 740854 Phone (714) 994 0402 Address 7431 Walnut Avenue City/State/Zip Buena Park, CA 90620 Consultant/Sub-Contractor E2C Remediation License# 855819 Phone (916) 782 8700 Address 1020 Winding Creek Road, Suite 110 city/stat ip Roseville, CA 95678 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells IRequire Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q(MONITORING of HOLLOW STEM BORING DEPTH 15 ft, 40fes_❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapcfMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ' all ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS ,5Crr. 4U TvPE OF CASING: ❑STc'EL X PVC ❑ OTHER SOIL BORING 10 PUSH POINT(GP/CPT; CONDUCTOR CASING ❑Yes K Nc Boring DiaCasing Dia: Casing Depth ❑ INJECTION,Air Soarae ozonei ❑ HAND AUGER GROUT SEAL DEPTH 16 ft TREtdIE TYPE TO BE USED C3 AUGERS ❑HOSE PIPE ❑ OTHER Cl OTHER GROUT SEAL PUMPED? ❑Yes 10 No ;Note Maximum Freefall Depth's 30 Ft) WELL/SOIL BORING IDs STSTMT94, B5,B6,B7, B8, GROUT SPECIFICATIONS NPat-cement Grout B9,E110, B-11, B-12 B-13 MW-11, li MW-3 MW-4 DESTRUCTION WORD TO Bt PERFORMED: DES RUCTION METHOD: )CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth offeet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE : ❑ ❑ ❑ El BE USED COMMENTS: AUGERS HOSE PIPE ❑MUSHROOM CAP 3 feet below surface or feet below surface if>3 feet CO 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 Califomia laws. Signed Title/Company Principal Engineer/E2C Remediaiton Print Name Aiguo Xu Date 12/5/2017 DEPARTMENT USE ONLY Application Accepted By Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facillt /Site Information kName FA Address FA# PR# WP Reviewed By Work Plan Date tC1Autho^.zation for Other to Sign Permit ❑Worker s Comp ❑Workers Camp Waiver ❑Enwament Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE sc FEE INFO AMT REMITTED CHECK# RECV D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 WWw.Sjcehd.com EHD 29-01 0B-01.17 Site Miugation Well Permit Application I5,zJ 3 try L�( .z