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SAN JOAQUIN Environmental Health Department COUNTY — - 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 1200 Humpfreys (See Work Plan) City/State/Zip Stockton , CA 95203 Phone (209) 946-0246 Cross Street (See Work Plan) APN 16203007 Property Owner* Port of Stockton Phone (209) 946-0246 Address 2201 West Washington St City/State/Zip Stockton CA 95203 C-57 Contractor PeneCore Drilling Inc. License# 906899 Phone (530) 661 -3600 Address 220 N . East Street City/State/Zip Woodland , CA 95776 Consultant/Sub-Contractor Geosyntec Consultants License# Phone (510) 836-3034 Address 1111 Broadway 6th Floor City/State/Zip Oakland , CA 94607 CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 ft bgs ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA, OF BOREHOLE —3 1 /4" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA x❑ SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Ar Sparge Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs (See Work Plan) GROUT SPECIFICATIONS (See Work Plan) DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ElPRESSURE 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 : I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaqui County Ordinance C ries and Standards, and all other applicable California laws. Signed Title/Company Senior Geologist Print Name Kimberly Brandt Date 05/23/2019 DEPARTMENT USE ONLY Application Accepted By: /VpSG #A~ 044orytZrW Date Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name o aF G+0 c. k 4orn FA Address l zc ) hluw• has FA# Lin 2 �,— � �0 PR# 0 Sy yo FA PE WP Reviewed By N9SB6 Work Plan Date ❑ C-57 C-57 Authorization for Other to Sign Permit ®'Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement [Lead Agency Approval Q'MFR COMMENTS/CONDITIONS : ALL �,y�uv�liv a � LLQ Jo Vgr `bl 6c o %+ c1 � ' '4'We'? S. W u hY�fti 6p� /Py ><o.� �at �S/�r�// F�rr�. .�� fa ��'� l � w, �11 �� & &4 WP TYPE PE SC I FEE INFO JAMIT REMITTED1 CHECK# I RECV' D BY I DATE I WELL PERMIT# INVOICE# Permit ZV,f 3/3 $152 x 3 JS Yr6p r1 I 330 "* I 6 -7-19 1 a W,*0 390 7/, 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468-3420 F 209 464=0138 1 www . sjcehd . com EHD 2"1 OB-01 -17 Site Mitigation Well Permit Application WdfA �a., Z 03 3 a3 .'i3 iX 3 '41fifG • orJ 3� /�'� G - 7— �! s'4##� AV 7101