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1 I SAN J O A Q U I N Environmental Health Department 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 2222 S.Airport Way City/State/Zip Stockton,CA 95206 Phone Cross Street E. 8th Street APN 169-163-010-000 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 Contractor V&W Drilling /� License# #720904 Phone p(209)469-7700 Address1'� ��33 �9G �1/ $�' y/l City/State/ZipLh'40 9,'rte Q/ 'C,4 /,j�-9"' ConsultanUSub-Contractor Condor Earth License# John Lane, PG#6795 Phone (209)234-0518 Address 188 Frank West Circle#1 City/State/Zip Stockton, CA 95206 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH SV 5.5ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE [EXTRACTION(VaporlWalerl ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25 Inches ❑MULTIPLE CASINGS❑MULTI-LEVEL YLL CASING DIA g SOIL VAPOR PROBE 1 MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC M OTHER Q•125°O.D.Teflon Tubing ❑ SOIL BORING PUSH POINT(GPI CPT) CONDUCTOR CASING C1 Yes No Boring Dia Casing Dia: Casing Depth: 5 feet ❑ INJECTION(Air Spam,Oz2NI _❑ HAND AUGER GROUT SEAL DEPTH / TREMIE TYPE TO BE USED. [I AUGERS [I HOSE ❑PIPE [I OTHER _ _❑ OTHER:--- GROUT SEAL PUMPED? ❑Yes L�1 No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs SV-2 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 ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: J hereft_certify that I am authorized to complete this application and that the work will be done In accordance with S1an_(`lpaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed i�` �—!'/ l'1 Title/Company -T-,A ND Print Name r i f �� EL,'e Date 04 o y�/ q T D ENT USE ONLY Application Accepted By: I Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name -'iC`A N t� R FA Address ' Z222 `I u Z`f S• FA# `{2 PR# - E)SiLA FA PE 20I5U WP Reviewed By L Work Plan Date 3 CIC-57 57 Authorization for Other to Sign Permit akei s comp ❑workers comp waiver ❑Encroachment Permit cress Agreement ❑Lead Agency Approval fft�R COMMENTS/CONDITIONS: WP TYPE PE SC I FEE INFO JAMIT REMITTED1 CHECK#I RECV-D BY I DATE I WELL PERMIT# INVOICE# Permit -Z� O 313 1$152 x 1 4 (SZ 1 157 L 111111 1 W foo Co 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2"1 OA-01-17 Site Mitigation Well Permit Application