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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 • meq... N'P Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sicehd.cotn LIFO" \ 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 C•E . t>t X 0 N S T R E ET' City/State/Zip S TO G K TO N , C.A Phone (209)9 5 3- 8 51 0 Cross Street LOCKHEED COVRr APN 111-260- 31 95206 Property Owner' S T o c k To N M E T R o P o L t r A tV A I R P o tt r Phone (t 0 9)`t 6 9- `i}00 Address 5 00 0 S, A i R P o R T WAY City/State/zip s T6 c R T 0 N ICA 9 5 2 0 6 C-57 Contractor V 4r W P R 1 L L I N 6{ INC. License# C-5} to, 2 0 9 0 4 Phone (to 9) 4 6 9 -"t}o 0 Address 3806 DUCK CHEEK DRIVE City/statelzip 5T0cKrari CA 95215 Consultant/Sub-Contractor RAMA(rE ENVIRDNMIiNTA L 1(I C.License# f.G. # 5856 Phone (11S) 651-1239 Address P•O, Go)( 19 3 5 3 City/State/Zip R EKO, NV B 3 S 11 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BoringsNVells Require AccessAgreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS NA /� i ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ElSTOVE PIPE [IEXTRACTION(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 Ola: Casing Dia: Casing Depth: ❑ INJECTION(Air Souae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freetall 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 7- ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs MW-1 M W-$ [f PRESSURE GROUT To depth of 3 feet below surface GROUT SPECIFICATIONS N V AT p O RT L A N D CEMENT ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE Q' PIPE [9MUSHROOM CAP W3 feet below surface or feet below surface if>3 feet cOMMENTs: RAFIAGE ENYMONMENTAL WORVK PLAN, DATF_D TUNE 1.9r2015 (RTTACHED) EI.1D WORK PLAN &pf KOVAL Lr T'CER, t)ATI`D TVNE 30, -,015 (ATTAtRED) I hereby certify that I am authorized to complete this application and that the work will be done in accordance with S an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed o��,.,�.�.,It_- Title/Company CORP, P R F:S. R A H Ar C E I-NV, INC , Print Name TO$ FrH KAMAfrE Date la �t6 SIS DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Informa on FA Name FA Address FA# PR# FA PE I WP Reviewed By IWork Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver []Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# I Work Pian I �^ Permit 2)UG J $130 x �_ Z 6 U /0,9/45 R 4p�3�Z5 EHD 29-016-23-2015 Site Mitigation Well Permit Application