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Date Issued: 1)01 'LA <br />SANIJOAQUIN <br />wria —COUNTY -- <br />.,a(Szoor, eatness (vows here <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 2103 Country Club Blvd City/State/Zip Stockton, CA 95204 Phone NA <br />Cross Street Franklin Avenue ApN 123-080-29 <br />Phone NA Property Owner. Mark Springs <br />City/State/Zip Stockton, CA 95209 Address 3535 Windham Circle <br />C-57 Contractor Confluence License# 913194 Phone 916-760-7641 <br />Address 3308 El Camino Avenue, Ste. 300 #148 City/State/Zip Sacramento, CA 95821 <br />Consultant/Sub-Contractor GHD License# 855376 Phone 916-865-0927 <br />Address 943 Reserve Drive City/State/Zip Roseville, CA 95678 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Of/site Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />CI MONITORING <br />El EXTRACTION (VaporPNater) <br />1:1 SOIL VAPOR PROBE <br />Et SOIL BORING <br />INJECTION (Air Some. °met <br />OTHER <br />NUMBER <br /> <br />INSTALLATION TYPE <br />HOLLOW STEM <br />1:1 HAMMERIDRIVEN <br />EI MUD ROTARY <br />PUSH POINT (GPI CPT) <br /> S. HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 1 1- El BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 1:1 OTHER <br />CONDUCTOR CASING 0 Yes El No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefalt Depth is 30 Ft) <br />WELL/ SOIL BORING IDs 8-9 and 8-10 GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREM1E TYPE TO BE USED 0 AUGERS 0 HOSE 0 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 />0 EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Sap Joaquin Comity Ordinance Codes and Standards, and all other applicable California laws. - - <br />Print Name Ben Summersett Date 10/17/2018 <br />DEPARTMENT USE ONLY <br />Signed Title/Company Scientist/GHD <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name v..41 CAydro" 61A0751,1 FA Address at03 C A CJba attit( FA# 00 '2...4,(1 ".5.-. PR# 0 S-4 Necti <br />FA PE dll' QV <br />wp eviewed By )-, -.;c Work Plan Date yi <br />0 c-57 5K-57 Authorization for Other to Sign Permit Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement MIL' ead Agen Approval 1AFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECY'D BY DATE WELL PERMIT# INVOICE# <br />Permit 3(.0105 301 $152 x :1. <br />i 3°1-1 It G lil i f g).7-'10 :017003V1/41 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />je tVj 52., A ts-1-4 tt.510 t cq-1 tort,s1 ig sci-0 311'5