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S A N 10 AQ U I N Environmental Health Department COUNTY Greorrrt.�s yrows ncre,. 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 perm t to construct and/or Install the work described This application Is made In con #lance with San Joaquin County Development Title,Chapter 1�-1115.3.and the San Joaquin County Well Standards. 2700 West Washington Street Stockton,CA 95203 Job Address Clty/StatalZlp Phone Cross Street Navy Dnve APN 145-030-12 Property Owner'' Port of StocktO Plana (209)946-0246 Address 2201 West Washington Street Clty/Stateop Stockton, CA 95201 C-67 Contractor Woodward Drilling Company Inc License# 710079 Photo (707)374-4300 Address 550 River Road Clty/statemp Rio Meta,CA 94571 ConsultanUSub-Contractor Orion Environn-antal License# Phone 510 525-2180 Address 2332 5th Street,Suite B City/ststemp _Berkeley,CA 94710 CONSTRUCTION WORK TO BE PERFORMED:*Note- Offske Borklgsl is Require Access Agreements or Encroachment Pemuts TYPE OF Mt I MORNG WjMl3Lg INSTALIATM TYPE CONSTRUCTION SPECIFICATIONS ❑ MONMTORNG ❑ HOLLOW STEM BORING DEPTH _— ❑BOLTED TRAFFIC BOX ❑STOVE PPE ❑ EXTRACTION(VW-WAK) ❑ HA&E VDRNEN DU.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA - ❑ SOIL VAPOR PROM ❑ AM ROTARY CASING THICKNESS __--TYPE OF CASING ❑STEEL❑PVC ❑ GTHER ❑ SOIL BORING __❑ RM POINT rR CPT) CON(WTOR CASING ❑YN O No BaY+q Die. CS&V Dr: CNN Orph ❑ INJECTION WMEn,=l ❑ HAND AUGER GROUT SEAL DEPTH TREME TYPE TO BE USED, ❑AUGERS ❑HOSE ❑PPE ❑ OTHER ❑ OTHER r'ROUT SEAL PUMIW ❑Ya ❑No (Nbb Madnan FIMW Doo Y X Fil WELU SOIL BORING Cc GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED- DESTRUCTION MOD:(CHECK ALL THAT APPLY) s WELLS TO BE DESTROYED 31 ©OVER-BORE DIAMETER of 9 _irctm b depMi d17 5-37 ted WELL IDs os-m b osae os41 os-43 b os.ei-os4e a OS-7JB Os-1-88 a bs-ti [3pREsSUREGR0lJX To depth of _---__,feet below surface GROUT SPECIFICATIONS at ement ❑EXPLOSNE om b het bAm surface TREMIE TYPE TO BE USE UGERS HOSE PIPE ROOM CAIY 03 feet below surface or het blow NOW@ If>3 toot '' `, ^A _ K coMIItENTs: j �I. �i ; A Ad� jy rprCss.Me�luro Csu a%Wells will be o r-bo unless site co p o ibit ugers?�)&� variance for pressure g t will be toquested. I hereby certify that 1 am authorized to complete this application and that the work will be dorm in accordance with ®L_' San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. �G Signed } T'db/COmpany Project Geologist, Oran Environmental Prktt Name Slott Stromberg Date 9/27/19 qGD 1 DEEARTMENT USE ONLY Application Accepted By _Dale Issued: Grout Inspection By/DateS. Destruction Inspection By/Dates f FacIIit :Silo Information FA Nam 7+r�c FA Address 3oO3 0 a..V FA# 0�2�}-rL9 I 4 � FA PE I - 'L { Gi O WP Reviewed By / V4 a C g Wotk Plan Dab ,lc V §jcs7 h*vIzAw lor dw b sqn P*ft ❑wareh coop ❑waver:Caro wsA.r ❑I:nctortnwlt PdnW ❑Aaas Aae~ ❑t,eett Agency Aw"M l7 MFR _ OMb=rJTSICONDITIONS:1 .C ` I k-?'er" :5'sc- l d S`r 3.I�.t p� �..tie� Fir{I� D�ace#u�7f� j++� NL4flrlal�S�vJr .R� +MSC Ir WP TYPE' PEA-roT sC FEE INFO AMT REMITTED CHECK# REWD BY Dl TE ' ERM1T#, 1WOICE# Perrnil Zg oZ ?J`3 5152 x 5 V CC 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 46"138 1 www.sjcehd.com EHD 2p-01 08-W-17 Sss M*p*M vw P«mt AWkftW S�,p D$I Z3 8