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G3lEC I [IMOD gUlry�` SALOOM JAN 01 201BEnvironmental Health Department ' —COUNTY— Greatness COUNTY Greatness grows her �zu ENVIRONMENT HEALTH s. 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 1744 West Hammer Lane City/State/Zip Stockton, CA 95209 Phone Cross Street Brentwood Drive APN 077-280-31 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/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS A MONITORING ❑ HOLLOW STEM BORING DEPTH 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ISOILVAPORPROBE El MUD ROTARY CASING THICKNESS TYPE-OF CASING: ❑STEEL [I PVC NOTHER 1/4" Nylon Tubing SOIL BORING ]ICI PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes XI No Boring Dia: Casing Dia: Casing Depth: y❑ INJECTION(Air soame.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE CK PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes IQ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B5, B6, B7, 68, B9,610, B-11, GROUT SPECIFICATIONS Hydrated hentonite, grannular hp-ri to B-12, B-13 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: Z Grout Inspection By/Dates: IV2, Uzzq 10 Destruction Inspection By/Dates: Facilit /Site Information FA Name4FA Address v1 ` u Kw,.wLaw` FA# ) 0 L43'lei PR# �iCc/ r6 FA PE WP Reviewed By I L-x Work Plan Date ll ❑C-57 57 Authorization for Other to Sign Permit 216kers Comp OP❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement I$•Cead Agency Approval FR COMMENTS/CONDITIONS: t-e.��c-at{ cwy{ G�Y� +,,v0�. .�.cn�' Ce"'"e^�`�. ^^ -#'4� iti.g- bot4o�^^ c� �- �•rc ho4c� }o 0, M.n�� 1 ` r✓�C v. rn WP TYPE I PE I SC I FEE INFO AMT REMITTED CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# Permit j��1,0 .l I 1$152x ;� ��(D L 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application