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agF4 ., SAN JOAQUIN COUNTY y ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 P Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com 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 Streets in the vicinity of 8606 Thornton Road City/State/Zip Stoclon,CA 95209 Phone Cross Street Deme SL,Ponce de Leon Aae.,Brei.d wy.end Wwdn t Wy. APN Yf74.448.49 f✓b t• k W f Of U-6 3 Property Owner' City of Stockton Phone Address 245 N.EI Dorado Street City/State/Zip Stockton,CA 92020 C-57 Contractor Gregg Drilling 8 Testing Inc. License# 485165 Phone (925)313-5300 Address 950 Howe Road City/StatelZip Martinez CA 94553 Consultantsub-Contractor ATC Group Services LLC License# 755604 Phone (209)579-2221 Address 1117 Lone Palm Avenue,Suite 201B CitylStatelZip Modesto CA 95351 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 110n ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) 0 HAMMERDRIVEN DIAOFBOREHOLE ma•.-tmmn ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER © SOILBORING saon.msEl PUSH POINT(GPICPT) CONDUCTORCASING ❑Yas ONO Boding Dla: Casing Dia: Casing Depth: ❑ INJECTION Wseaee.gzanl ❑ HANDAUGER GROUTSEALDEPTH 11011. TREMIE TYPE TO BE USED: [I AUGERS r]HOSE EIPIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freetell Depth is 30 Ft) VIEW SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) !, #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—inches be depth of feet WELL IDs ❑PRESSUREGROUT To depth of_feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: In total there will be (25)4" diameter borings installed. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with In Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed QIin, /�/ $YVnd/y Title/Company Branch Manager/ATC Group Services LLC Print Name J nne Hornsey Date October 13.2016 �/� DEPARTMENT USE ONLY Application Accepted By: %G+uifC�G�s,'.�/.�-r. . Date Issued: Grout Inspection By/Dales: Destruction Inspection By/Dates: Facilil /Site Information FA Name FA Address FA# 7/ PR# OSS��3S7 FA PE WP Hewed BY / s�q' Wark Plan Date O57 57Auteiugonfa0therto Sign Permit ETWOrkersCorrp ❑Wodicers Comp WaNer OfiaoschmenlPermit ❑Aaess Agreement AgenTApp6W R COMMENTS/CONDITIONS: 2�Y,n3J t,, y� ✓t..J'fGwe G/7"�o�/ Y�cll x✓r yk �J«,`I"•� �t•><24tf hTGt�j' t o/i'•oll maj hr 411 A7le{� W>x !/n rvn.d<�utfr'y 71 lc6f1 I SR TYPE PE I SC I FEE INFO JAMT REMiTTED1 CHECK#I RECV'D BY DATE SERVICE REQUEST# INVOICE# work Plan 2903 5z3 I G// 7 1 4 y/J' 01,01,7S cNro/ .S iP�a�L�7 Permit 29v5 3r s13yX 3 y/7 - ac��rs �,vire� s/Aao7';wE0 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application