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Consultant/Sub-Contractor Partner ESI License# Phone 510-410-1009 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information DEPARTMENT USE ONLY Date Issued: t-ths, SANAOAQUIN Environmental Health Department COUNTY c r---1°9'14‘r Greatness grows here. 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 1021 East Hazelton Avenue city/state/zip Stockton, CA 95203 Phone 510-410-1009 Cross Street South Union Street APN 151-280-030 Property Owner* Sheldon Doss (sdoss@dosstrucking.com) Phone 707-974-4456 Address 3775 Brickway Boulevard, Unit 100 City/State/Zip Santa Rosa, CA 95403 C-57 Contractor ECA, Inc. License# 69570 Phone 831-662-8178 Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 Address 1017 22nd Avenue, Suite 107 City/State/Zip Oakland, CA 94606 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE 12 MONITORING HOLLOW STEM EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN SOIL VAPOR PROBE 0 MUD ROTARY NI SOIL BORING 10 PUSH POINT (GP/ CPT) El INJECTION (Air Sparse, Ozonel HAND AUGER OTHER OTHER: WELU SOIL BORING IDs B1 thru B10 CONSTRUCTION SPECIFICATIONS BORING DEPTH 10-20' ID BOLTED TRAFFIC BOX 0 STOVE PIPE DIA. OF BOREHOLE 2.5" 0 MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: III STEEL 0 PVC 0 OTHER CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Die: Casing Depth: GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 3() Ft) GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE CI PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 1=1 OVER-BORE DIAMETER of inches to depth of feet CI PRESSURE GROUT To depth of feet below surface Cl EXPLOSIVES From to feet below surface I1 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet COMMENTS: Advance a total of 10 Geoprobe borings including six borings to 10' bgs and four borings to 20' bgs for soil, soil gas, and/or groundwater sampling. ereby 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. Title/Company Project Manager / Partner ESI Print Name Joe Manpine Date 7/3/18 FA Name , 7....1 Rz,z,e 1 kiN Asa_ FA Address toti c FA# 007_4 i . 1 PR# octi 3531 PE }-9 FA 9) WE Reviewed By (.- —)( Work Plan Date 7 / Lit r- ID C-57Iff C-57 Authorization for Other to Sign Permit Eiliorker's Comp 0 Worker's Comp Waiver ID Encroachment Permit 0 Access Agreement ID Lead Agency Approval f8<F-R COMMENTS/CONDITIONS: i iu\,t t'LVA;V-C-, '.....k4-k• S V-AAA Iebc_ Ci-friv-^e----ft,1(-4-1-141'-'-vs-c-4,- .-"z-c-01 c'-'- ok,4.c-5. cos,e_al .. WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECIPD BY DATE I WELL PERMIT# INVOICE# Permit 2_61,0 5 31 3, $152x .3 4 •tri, v";:it)ifill L-11 111114 4-1r00A-Ce9 1 1868 E, Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-04-08-01-17 Site Mitigation Well Permit Application Signed