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oP4 In• SAN JOAQUIN COUNTY 2r y ENVIRONMENTAL HEALTH DEPARTMENT >'�"� � 3: • 1868 Hazelton Avenue, Stockton , CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com 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 2025 W. Hazelton Ave City/StatelZlp Stockton , CA 95203 Phone 209-946-0246 Cross Street S . Ventura Ave APN 145-030-06 Property Owner* George Weinberger Phone 209-639-1211 Address 40 Belarave Ave City/State/Zip San Francisco, CA 94117 C-57 Contractor Cascade Drilling License# 938110 Phone 916-638-1169 Address 3000 Duluth St City/State/Zip Sacramento, CA 95691 ConsultanVSub-Contractor CH2M License# N/A Phone 510-587-7557 Address 155 Grand Ave Suite 800 City/State/Zip Oakland CA 94612 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 6 ft bgs ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (VaporMater) EI HAMMERIDRIVEN DIA. OF BOREHOLE 4" ❑ MULTIPLE CASINGS ❑ MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER E SOIL BORING 24 ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING El Yes [I No Boring Dia: Casing Dia: Gasing Depth: ❑ INJECTION (Ar some. ozone) O HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes 0N (Note: Maximum Freefall Depth is 30 FI) WELD SOIL BORING IDs 21<, 5K, and 6K (eight borings in each GROUT SPECIFICATIONS Neat cement will be poured into the hole once soil samples have been collected. sampling area) 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 ❑ PRESSURE GROUT To depth of _ feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feel below surface or feel 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 Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed �--- Title/Company Geologist / CH2M Print Name Jenny Salinas Date 7/29/2016 /� � DEPARTMENT USE ONLY Application Accepted By: � ��aG.�_. Date Issued: 09117/G Grout Inspection By/Dates: Destruction Inspection By/Dates: Facllit /Site Information FA Name a - FA Address ZOZ /�/- FA# eloo O t PR# O.i O 80 FA PE WP Reviewed By I I Work Plan Date ITriKt Zq' LIC-57t�7 Authorization for Other to Sign Permit marker's Comp ❑ Workefs Comp Waiver G2{mcroachmem Permit EiA�cess Agreement 9ambTAgency Approval R COMMENTS/CONDITIONS: �ro✓f ��vyAA'�lan, e� 6piih1rs i+'1fPo/f1"dCewe4tf eef� otr -T )c crw fie c(c�c,1 /lccfvc S SR TYPE PE SC I FEE INFO JAMT REmiTTED1 CHECK# I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# Work Plan 2903 523 1 .y/ 7 "oy17 ms 1 154007*3rd1W Permit 2905 313 Isi 9 x j Po'll7 1 I>59ff`1Z I I feac) 753f0 IS CoHkVr EHD 29-016-23-2015 Site Mitigation Well Permit Application