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Job Address MCKINLEY PARK @ S. SAN JOAQUIN ST. <br />Cross Street W. 8TH ST. <br />Property Owner* CITY OF STOCKTON <br />Address <br /> 425 N EL DORADO ST <br />C-57 Contractor ALL WELL ABANDONMENT <br />Address 3369 FITZGERALD RD STE. B <br />Consultant/Sub-Contractor AGE <br />Address 837 SHAW ROAD <br />City/State/Zip STOCKTON, CA 95206 Phone <br />APN 167-060-010-000 <br />Phone (209) 937-8444 <br />City/State/Zip STOCKTON, CA 95202 <br />(916) 363-9355 License# 848359 Phone <br />City/State/Zip RANCHO CORDOVA, CA 95742 <br />(209) 467-1006 License# 680227 Phone <br />City/State/Zip STOCKTON, CA 95215 <br />SANJOAQUIN <br /> <br />Environmental Health Department <br />COUNTY— <br />Greatness grows hen' <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <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 />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE <br />MONITORING K] HOLLOW STEM <br />ID EXTRACTION (Vapor/Water) ID HAMMER/DRIVEN <br />SOIL VAPOR PROBE El MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Spam, Ozonel D HAND AUGER <br />0 OTHER I: OTHER: <br />WELL/ SOIL BORING IDs B-16, B-17 1144r <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 125' <br /> <br />L1 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 8.25" <br /> <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS <br /> <br />TYPE OF CASING: 0 STEEL 0 PVC D OTHER <br />CONDUCTOR CASING <br /> <br />o Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH <br />125' <br /> <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE Zi PIPE <br />GROUT SEAL PUMPED? ($) Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />PORTLAND CEMENT TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE P PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />CI EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: SEE WORK PLAN DATED 25 OCTOBER 2016; WATER TO BE DISPLACED THROUGH DIVERTER ATTACHED TO AUGERS, VACUUM <br />ON STANDBY TO USE AS NEEDED. <br />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 />Signed \-k_,A),A A A4C,kr.A.AA.,..„ Title/Company STAFF GEOLOGIST / AGE <br />Print Name ERIN ROTTACKER Date 09 AUGUST 2018 <br />DEPARTMENT USE ONLY <br />/z ilk Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />4t1 L.)( ty rl'ku X it P-f //vi' <br />FA Name M t:"tj i ii i , ii er.of .e.,,,f,/ FA Address Li ''. E- ' - '- - - -.2. i i-- 1 \),..,,,{4,. ...1 r FA# cc Ls, i i FR# <br />FA PE e-D-Pt (0-0 WP Reviewed By t.—" Work Plan Date -3) — i \ 0. <br />I=1 C-57 Q C-57 Authorization for Other to Sign Permit 0"VVorker's Comp 0 Worker's Comp Waiver 3<nCroachment Permit 0 Access Agreement ci Lead Agency Approval Eriv't-FR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit -)51,,,5' 5,1, $152 x 2. 4 3 zi Li 1 L Y 81-tliix <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