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16rZ7-r11- S A N,J O A Q U I N Environmental Health Department COUNTY Greatness grows here. m�0 C SITE MITIGATION WELL & BORING PERMIT APPLICATION m z For Wells and Borings Used for Contaminant Investigations and Remediation N NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y y o 48 Hours Advance Notice Required For All Inspections 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 434 Dr. Martin Luther King Jr. Blvd City/State/Zip Stockton, CA 95206 Phone (510) 410-1005 Cross Street California Street APN 167-150-31 Property Owner' Lynne Ba l l ew Phone (8 5 8) 775-8885 Address 2004 Mesquite Court City/State/Zip Carlsbad, CA 92009 C-57Contractor Environmental Control Associates, Inc. (ECA) License# #695970 Phone (831) 662-8178 Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 Consultant/Sub-Contractor Partner Engineering and Science License# Phone (510) 410-100S Address 1017 22nd Avenue Suite 107 City/State/Zip Oakland, CA 94606 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 30 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapodWater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 7 - 5 i n - ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 5 ❑ 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:Direct- GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B1, B2 , B3 , Push GROUT SPECIFICATIONS B4 , BS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 5 t em_p o r a r v wells ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs B1, B2, B3, B 4, B5 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP [-13 feet below surface or feet below surface if>3 feet SOMMIENTS: rilling a total of five borings to 30 feet bgs, or groundwater whhichever is shallower, for the collect or �g of soil and groundwater samples. Destruct borings same day yrouMhien cap with - .��5 (�&(} I hereby certify that I am authorized to complete this application and that the work will be done in accordance with u✓ San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. C0Kcv-t+c Signed. ��°" "` Title/Company Partner Engineering and Science Print Name Nathan Maroon Date August 21, 2017 / DEPARTMENT USE ONLY Application Accepted By: J i Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name 1 j LFAAddress �3 �. 1 �.k�'� �.�. � FA# r) ) ZZPR# iJtq FA PE •-,, Reviewed By . Work Plan DateC]C-57 ®1557 Authorization for Other to Sign Permitrker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval Q'�FR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE ,pWELL PERMIT# INVOICE# Permit V CJG?- 3,13 $152 x y D 13L,02- i- x (� _ -7 VJ 2-4,� 1868 E. Hazelton Avenue I Stockton. California 95205 1 Y209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application