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SAN JOAQUIN <br />COUN T" <br />Environmental Health Department <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 />Job Address 705 Carlton Avenue city/state/zip Stockton/CA/95203 Phone <br />Cross Street Park Street ApN 133-210-05 <br />Property Owner* Vertiv Group Corporation (Attn: Jacob Watson) <br />Address 1050 Dearborn Drive <br />0-57 Contractor Environmental Control Associates (ECA) <br />Address 3011 Twin Palms Drive <br />Consultant/Sub-Contractor EFI Global <br />Address 433 Airport Blvd., Ste 303 <br />CONSTRUCTION WORK TO BE PERFORMED: Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />Phone 440-288-1122 <br />City/State/Zip Columbus/OH/43085 <br />ueense# 695970 <br />City/State/zip Aptos/CA/95003 <br />License# 885902 Phone 415-857-8517 <br />City/State/Zip Burlingame/CA/94010 <br />Phone 916-417-8179 <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE <br />MONITORING 0 HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />DK SOIL BORING 2 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Soarer Clonal 0 HAND AUGER <br />OTHER E:1 OTHER Direct Push <br />VVELU SOIL BORING IDs B1, B2 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />C OMMENTS: <br />0 AUGERS 0 HOSE 0 PIPE <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 10 feet bqs 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 9 25 inrhps 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS N/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes M No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 12 PIPE <br />GROUT SEAL PUMPED? 0 Yes IN No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Cement grout from terminal depth to within 6 inches of surface in <br />each boring. Resurface with concrete. <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />El OVER-BORE DIAMETER of inches to depth of feet <br /> 0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP I:13feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaqui ciottniy Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 14t1e/Company President / ECA - <br />t-'1,7,* conr%cA k)c) Con 4•0\ 'C f9ate i P/ /2-011( Print Name Tim Tyler <br /> <br />DEPARTMENT USE ONLY <br />Date Issued: hf <br />ID /it h <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br /> <br />Facility/Site <br />FA Name <br />Information <br />FA Address <br />— () <br />-V; N . GArt-s.n. Avk.L. FA# (902)-4-71 PR# 09-131 ir.".3 <br />FA PE 2.S12 WP Reviewed By 1...- ---)( Wok Plan Date <br />1 <br />"-' <br />b t 1 1-Ad <br />0 0-57 lirAuthonzation for Other to Sign Permit giV/c;-rker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval -5144 <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE* <br />Permit tilos-- 3 i3 _ $152 x 2_, 4 '3 0,1 OlVjoic L' -,C iciii k we003 s-k-s 0 <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 Sae Mitigation Well Permit Appication