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I --wet-,aC C�C[IM�DD SANsJ0A0UINEnvironmental Health Department —COUNTY—JAN 0 2 2018 Greatness grows here. �Clpn;" ENVIRONMENT HEALTH 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 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 1762 West Hammer Lane City/State/Zip 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/State/Zip Roseville, CA 95678 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Q MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE-OF CASING: El STEEL ❑PVC DC OTHER 1/4" Nylon Tubing SOIL BORING PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes XI No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes DQ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs84 GROUT SPECIFICATIONS Hydrated bentonite- arannular hentonite DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM 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_ _ Title/Company Principal Engineer/ E2C Remediaiton Print Name Aiguo Xu Date 12/29/2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: � .f h3 -f 0 T Destruction Inspection By/Dates: Facilit /Site/IInformation FA Name 1R�r( -wL��` c lvr t�' FA Address I'1 N`i �} �{� r nrt�f �C.rv2 FA# 002--%�cjj PR# FA PE ��Q WP Reviewed By Work Plan Date i\ s ❑C-57 UG57 Authorization for Other to Sign Permit t Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement Eg'Cead Agency'Approval FR COMM ENTS/CONDITI{ONS: I\ '" '4-: -+-'. . v �cr/ VC s vi t}4 Vl�—L CB e.�"4 -�y"^ 44-4- V146^1 ,T bo rL 1n.o le. r 4bL 4F a. WP TYPE I PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit Aot 1> $152x 1. �� LL'-% 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 _ - Site Mitigation ell Permit Application yjQ X05 ►Lf�4 �t'S S�vc�1 Net