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6JUL082p141LE COPS SAN JOAQUIN COUNTY RONMENTALHEALTH ENVIRONMENTAL HEALTH DEPARTI VITIRMITISERVICE LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/ehd �IFpR 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 Standards of the San Joaquin County Environmental Health Department - Site Location 8010 S. Airport Way Cross Street Stimson Street City/State Stockton, CA Zip 9'706 APN 1772600.1 Property CA A a , and #A &Aw-�j 10260 Mather Blvd. Mather, CA 95655 916-369-4375 Owner SMi-TE Address City/State Zip Phone C-57 Contractor Penecorc Drilling Address 220 N. East Street City/State Woodland, CALK '906899 Phone 530-681-3600 Consultant/Sub Cntr ECM, Inc. Address Billable Party CA Army National Guard Address GIS Coordinates: X -121.247 Y 37.8848 3525 Hyland Ave., Suite 200 10260 Mather Blvd - City/StateCosta Mesa, CALK ^778024 Phone City/State Mathcr, CA Zip "b" Phone il4-bbl-L/7Y 916-369-4375 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDs ❑ WELL IDs M OTHER IDS 36 - direct push injection points which will be installed in 2 mobilizations, 18 -borings during week of 7114/14 and 18 -borings during week of 8/11/14 TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 3 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 2 TYPE OF CASING: ❑ STEEL EI PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _L6_29 INJECTION fie Mr Sparge , Ozone/ C3 HAND AUGER GROUT SPECIFICATIONS Boreholes will be abandoned with neat cement after completion of iniections _❑ OTHER: ❑ OTHER: APPROX, BORING DEPTH 45 feet ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS. 36 - direct push iniccoon points for ISCO injections. Boreholes will be abandoned per SIEI11) regulations upon complcuion of injections NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(S) TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California laws. Signed Title/Company Project Manager - Sr. Geologist / ECM, Inc. Print Name Luis Mercado Date 7/1/2014 QQ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS DOJO WORK PLAN DATED J Lt LI Z , zo / 1_ APPLICATION ACCEPTED BY `l y'001< ftl DATE GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR# INVOICE co'� S125x I i cf %-3"/c SR# 70 Cr -)g 2,Qv 3%5 3500 PR # 2900 C-57 V WC l/ WAIVERw�_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ LNGRUAGHMLN I UUL —F/ EHD 29-01 5/09/12 WELL PERMIT APP