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P4 'l�•> SAN JOAQUIN COUNTY <br /> 2r ENVIRONMENTAL HEALTH DEPARTMENT <br /> '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*cehd.com <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. <br /> This application Is made In compliance with San Joaquin County Development Title, Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address Stockton Metropolitan Airport 5000 S Airport Way Clty/StatelziP Stockton, California 95206 Phone (209)468-4700 <br /> Cross Street Arch Airport Road APN 177-260-340 <br /> Property Owner' County of San Joaquin Phone (209)468-4700 <br /> Address 5000 S Airport Way CltylStatelzip Stockton,California 95206 <br /> C-57 Contractor M R Drilling License# C-57#740854 exp.,9 5 Phone <br /> 30%�/� — (714)994-0402 <br /> Address 13124 Firestone Blvd. CltylStatelzip Santa Fe Springs, CA 90670 <br /> Consultant/Sub-Contractor BSK Associates License# n/a Phone (559) 497-2880 <br /> Address _3140 Gold Camp Drive 0160 City/State/Zip Rancho Cordova, California 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: O#sfte Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 3 0 HOLLOWSTEM BORING DEPTH approx. Goff 0 BOLTED TRAFFICSOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapwAYalm) ❑ HAMMEWDRNEN DIA.OFBOREHOLE Rn ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS Sch 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> ❑ SOILSORING ❑ PUSH POINT(GPICPT) CONDUCTORCASING [I Yes ®No Bodng Dia: A" Casing Bra: 2" Casing Depth: 60ft <br /> ❑ INJECTION(AkSoxae.o eref ❑ HANDAUGER GROUT SEAL DEPTH Depth of boring TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I@PIPE <br /> ❑ OTHER OTHER: GROUT SEAL PUMPED? ®Yes []No (Nde:MW=mFree(a0 Depu1h30F9 <br /> WEWSOIL BORING IN _ _ GROUT SPECIFICATKINSNeat cement with S%hentonite <br /> DESTRUCTION WORK TO BE PERFORMED: n/a DESTRUCTION METHOD:(CHECK ALL THAT APPLYI <br /> #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth offeet <br /> WELL IOs -0 PRESSURE GROUT To depth of_feel below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feel belowsudace <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE 0PIPE El MUSHROOM CAP ❑3 feel below surface or feet baioNsurface if>3 feet <br /> COMMENTS: <br /> Ihereby certify that I am a9korized to complete this application and that the work will be done In accordance with <br /> Signed an Joaqul {sauce Codes ands andards Tit a/Company lP l other tyk,i applicable ICelifor�fa�law <br /> ;�. , / Q��. <br /> Print Name I IPt `' h / ryktr-fin Date 10 2OZ3 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: D elssue tt L'W L-L-7 <br /> Grout Inspection By"ates: Z <br /> Destruction Inspection By/Dates: <br /> Facliltv/Site Informatiop <br /> FA Name V 'L'1-W.� tFAAddress �,XJ �, , 1 FA# >. PR# <br /> FA PE v WP ReviewedB Work Plen Dale <br /> ❑Cd7 C57AUUeinfionfa00aloSWPermit ❑Workers Carp ❑Workers GompWahaz ❑Encroachment Permit OAaess Agreement Lead Agency Approval 4MFR <br /> _ COMMEN�,T�.S/C NDITIONS: TL.�_ 4\Y5, I� 7���y.j •U� -Fci ,���e�'t�-�IwL , Q,�. <br /> M� '. :vtSt'a� t�ti 1 L�1YltEL3 <br /> SR TYPE I PE SC I FEE INFO JAMT REMITTED1 CHECK# I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 7-'?':d ' ( 10, Y 3 <br /> (',v-�{fLL i�( 33 ��-�33 It•aa•�3 wrm04sm8� � <br /> EHD 29.01 6-23-2015 Site Mitigation Well Permit Application <br /> 1 <br />