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SAN.JOAQUIN Environmental Health Department COUNTY Greatness grows here. 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 Fisk Road and McKinley Road City/State/Zip Stockton, CA 95336 Phone N/A Cross Street Airport Road APN N/A Property Owner` County of San Joaquin -Department of Public Works Phone Address 1810 E. Hazelton Avenue City/State/Zip Stockton, CA 95201 C-57 contractor Gregg Drilling &Testing License# 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-ContractorAhtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 City/State/Zip Pleasant Hill, CA 94523 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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ 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(Air Soarae.Ozonel ❑ 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 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ®OVER-BORE DIAMETER of 6 inches to depth of 33.3 feet WELL IDs PZ001, PZ002, PZ004 ❑PRESSURE GROUT To depth of 0 feet below surface GROUT SPECIFICATIONS Cement bentonite grout ❑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: PZ001 TD 30.1 ft, PZ002 TD 30.1 ft, PZ004 TD 33.3 1 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 Sr. Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG Date August 29, 2018 PARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: l Facilit /Site Information FA Name M1 1 �{4yo FA Address FA# OG- 3 PR# FA PE `j�,S I ZcZS�( I ;2q>_Lj WP Reviewed By L ,,X Work Plan Date ❑C-57 157 Authorization for Other to Sign Permit orker s Comp [I Workers Comp Waiver Encroachment Permit [I Access Agreement Q Lead Agency Approval ErMFR COMMENTS/CON DITIONS:U'.V"e"y WP TYPE I PE SC FEE INFO JAMT REMITTED CHECK#I RECV-D BY DATE WELL PERMIT# INVOICE# Permit 9-fWL 313 $152 x 3 x'00 3 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application