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SAN JOAQUIN COUNTY lc� ENVIRONMENTAL HEALTH DEPARTMENT Q• •a • 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sucehd.com 4��FOR 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 1010 industrial Drive City/State/Zip Phone Cross Street South Airport Way APN 177-280-530-000 - Phone_ Address 2013WhelanAve>LUp City/State/Zip C-57 Contractor Confluence Technical Services,Inc License# 1035255 Phone 707-639-7709 Address 6821 8th Street City/State/Zip Rio Linda,CA 95673 Consultant/Sub-Contractor Terraphase Engineering Inc License# Phone 610-955-2248 Address 1300 Clay St,Ste 1000 City/State/Zip Oakland CA 94612 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 5.5 ft ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS 2'"' TYPE OF CASING: ❑STEEL❑ PVC ® OTHER 1/4-in OD nylaflow tubing ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ® HAND AUGER GROUT SEAL DEPTH 4 ft 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-*YO" S V—Q`7 GROUT SPECIFICATIONS Portland Type 1/II 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 ❑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 Joaquin County Ordinance Codes and Standards,and all other applicable California laws. 12 Signed �' & az_Q Title/Company Sr Project Geologist,Terraphase Engineering Print Name Molly Coates Date 2/3/26 DEPARTMENT USE ONLY Application Accepted By: ~ Date Issued: Z l ' nn,,_� Grout Inspection By/Dates: dI mt f nh rm � u'YY7t r- � w wivr Destruction Inspection By/Dates: w rnple toI 0inC KX, (k acr �pf 0 VID-n v� Vi4i it Tor 6rl pe P'i Facilit /Site Information FA Name !/Y >s.t�- S w FA Address �v l ri �w FA# PR# d ik(,,6 Oj FA PE -C7 WP Reviewed By Work Plan Date t j ❑C-57 79457 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ?Lead Agency Approval WFR COMMENTS/CONDITIONS: ,'U p cJ 7 j•v_1 t�LV�, ��c�/' G (� S"41L SR TYPE PE sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Lqo j 3t / L'+-PLX � c c_ a3 al(,Q W PaC�0I48a Pe � 130 x _.___i-, EHD 29-01 6-23-2015 Site Mitigation Well Permit Application