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f SAN 10AQUIN Environmental Health Department Lavit --COUNTY--- Greatness grows here. 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 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 2244 S.Airport Way City/state/Zip Stockton, CA 95206 Phone Cross Street E. 9th Street APN 169-151-010-000 Property Owner' City of Stockton Redevelopment Agency Phone (209)937-8539 Address 425 N. EI Dorado Street City/State/Zip Stockton, CA 95202 C-57 Contra for V&W Drilling License# #720904 Phone (209)469-7700 AddrestW" 13A6-BdCIf6Feek BF. 1133 V61 City/statemetteekten-eA-952 6411 Ch 951532 Consultant/Sub-Contractor Condor Earth License# John Lane, PG#6795 Phone (209)234-0518 Address 188 Frank West Circle#1 Citylstate/ZIp Stockton, CA 95206 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 SV 5.5ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE XTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.25 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL, LL CASING DIA 19 SOIL VAPOR PROBE �� MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [IPVC 1S0 OTHER Q.125"O.D.Teflon Tubing [I SOIL BORING PUSH POINT(GP!CPT) CONDUCTOR CASING ❑Yes No Boring Dia: Caskg Dia: Casing Depth: 5 feet ❑ INJECTION(Air Spam.Ozone l ❑ HAND AUGER GROUT SEAL DEPTH �/ TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes L�No (Note:Maximum Freefall Depth Is 30 Ft) WELL]SOIL BORING IDs SV-1, SV-3, SV-4 GROUT SPECIFICATIONS Neat Cement Grout or Bentonite Grout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS HOSE PIPE El MUSHROOM CAP El 3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with �an Joaquin County Ordinance Codes and Standards,and all poleraPpucubh.4`41Nornkl Mws' Signed----1`'��.�fi J— Title/Company o' y�o ,, 5 o Print Name F(--aDateZ' 7 C, / Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Faci i ! ite Information FA Name STAfJ D OLNk Le FA Address tut Ztt� S' 0 `r FA# j(9jD2,5-j,4Z. PR# SyyU4 FA PE 'n 5-0 WP Reviewed By L,'")(/ Work Plan Date 3 U ` ❑C-57 C-57 Authorization for Other to Sign Permit orkers Comp ❑worker's Comp waiver ❑Emoachment PermitAgreement [I Load Agency Appmval COMMENTS/CONDITIONS: ! _o�� "J"" ^" G ow1-1 . 7 WP TYPE PE SC FEE INFO AMT REmn-TED1 CHECK#I RECV-D BY DATE WELL PERMIT# INVOICE# Permit -m 313 $152 x I Lfq I `s-7 b /—Y 3 -z l 1868 E. Hazelton Avenue I Stockton, Califomia 95205 i T 209 468-3420 i F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Site Mitigation Wel Perron Application