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C� r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT •': = ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.cotnt 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 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 6484 N Waverly Rd. citylstatelzip Linden, CA 95236 Phone Cross street Floor Rd. APN 093-440-02 Property Owner* San Joaquin County Public Works Dept. Solid Waste Phone Address 1810 East Hazelton Ave. City/State/zip Stockton, CA 95205 C-57 Contractor Yellow Jacket Drilling License# 643081 Phone Address 9460 Lucas Ranch Rd. cityistatelzip Rancho Cucamonga, CA 91730 Consultant CB&I License# Address 1042 Willow Creek Road Suite A101, PMB 512 City/State/Zip Prescott, AZ 86301 209-468-3066 209-468-3066 (909)989-8563 Phone (619)279-4251 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER l ,:PW) INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ' MONITORING ❑ HOLLOW STEM BORING DEPTH 261 ❑ BOLTED TRAFFIC BOX ® STOVE PIPE EXTRACTION (Vapor/Water) )TJ HAMMERIDRIVEN DIA. OF BOREHOLE 10" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS 2" Triple Nest TYPE OF CASING: ❑ STEEL I@ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes (M No Boring Dia Casing Dia: Casing Depth: ❑ INJECTION (Air saame. Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 1M PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING 10s SG -3A Permit GROUT SPECIFICATIONS Medium Bentonite Chips $130 x DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI # WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: 1 hereby certify that i am authorized to complete this application and that the work will be done in accordance with San J uin County Ordinance Codes and Standards, and all other applicable California laws. Signed —Title/Company District Manager/ Yellow Jacket Print Name Dean Coblish DateMarch 29, 2016 Application Accepted By: /�$/7i L+ c! i3 /38 n/i kJ ✓d9 Date Issued: �'/� 2 - Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information -II-'r „'r 13 s4N. — FA Name l ,:PW) FA Address WP Reviewed By FA# I T-P-1wi I Work Plan Date FA PE ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Aocess Agreement ❑ Lead Agency Approval ❑ MFR COMMENTSlCONDITIONS:� -V2"W iq l SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE INVOICE# Work Plan LIV-71 3DO /36- 4 4/IZ I(O --11REQUEST# Permit $130 x O/ FSs7 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application