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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 c;•.:-:;:.�;:P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com �rF04� 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 --151 S. C.E . 01X0N STRI-VT City/State/zip STOGkTON - CA Phone (109)983- 85`}0 Cross Street LOCKHEED COURT APN 111-260- 31 95206 Property Owner* 57rocKTON METRaPOLtrAN AtRPORT Phone (2o9) 469- y}oo Address 5 0 o o S. A I R P o R T WAY City/State/Zip S Te C IRT 0 N t CA -9S Z0 6 C-57 Contractor V4 W P R I L L 1 N G, INC , License# C-5} # 1 2 0 9 0`} Phone (709) 40 -1-100 Address 3BO(o DycK CCLEEk DRIVE City/State/Zip STocKT'ON CA 95215 Consultant/Sub-Contractor RA MA(rf- ENV I RO N M E NTAL , I IA C.License# P.Cr. g 5 8 5 6 Phone (-t-+S 8 1-12 3 9 Address P-0, (3 o)( 19353 City/State/Zip RE N 0, NV 8 9 5 t 1 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits NA TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS l V A ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(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 Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 GROUT SPECIFICATIONS DESTRUCTION WORK TO,BE-PERFUlkMED: ? DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BEDESTROYE07-2 / ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs�1 W B [PRESSURE GROUT To depth of 3 feet below surface GROUT,SPECIFICATIONS-.N I-AT PORTLAND C E M E N T ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED E]AUGERS ❑HOSE Q PIPE [MUSHROOM CAP L7 3 feet below surface or feet below surface if>3 feet COMMENTS: RAMA(+-L ENVIRONMENTAL WORk, PLAN, DATCD .TUNE 19,101,5 CATTACNCD) END WORK PLAN APPROVAL Lr-T1'ER, t,AtF-0 7'VNL 3o, 201, 5 (ATTACNI=D) 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. Signed �o�.�„�,v,¢� Title/Company C o K P. P R C S. R A M R G C 1=N V. r IN C, Print Name T O S F P H R A M A V E Date to I 1 6 1 is DEPARTMENT USE ONLY Application Accepted By: d�!/i'� i�7T (i`m�'�y� Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: // �S' �r 4w ) � Facility/Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE l PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit Z)OZ >'/]' $130 x Z 26 O /0//,'/' /S SR 6 0752Z5 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application