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ri C u .,_,i {0 L O "' �� ' SAN JUN COUNTY � 4 �� ENVIRONMENTAL HEALTH DEPARTMENTLOP y ?� ENVIRONMENSITE A �7I ATION •' '�'`• 1868 Hazelton Avenue, Stockton, CA 95205-6232 PEPM;T/Sr s,F Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sogov.org/ehd UNIT IV 4�IFi7R 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 Standards of the San Joaquin County Environmental Health Department. Site Location 8010 S.Airport Way Cross Street Stimson Street City/State Stockton,CA Zip 95206 APN 17726004 Property CA Army National Guard 10260 Mather Blvd. Mather,CA 95655 916-369-4375 Owner Address City/State Zip Phone C-57 Contractor Penecore Drilling Address 220 N.Last Street City/State Woodland,CALic 0906899 Phone 530-661-3600 Consultant/Sub Cntr ECM,Inc. Address 3525 Hyland Ave.,Suite 200 City/StateCosta Mesa,CALic #778024 Phone 714-662-2759 Billable Party CA Army National Guard Address 10260 Mather Blvd. City/State Mather,CA Zip 95655 Phone 916-369-4375 GIS Coordinates:X -121.247 Y 37.8848 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ©OTHER IDs 28 DPT ISCO infections and 1 SB in 3 total mobilizations.5 DPT iniection points and one soil boring will be advanced through concrete slab(a)10-12 feet bqs. TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING NI HOLLOW STEM DIA.OF BOREHOLE 3"-6" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS 2 TYPE OF CASING: ❑STEEL M PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL N/A TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 1 Rl SOIL BORING IM PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 28 El INJECTION(Le.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Boreholes will be abandoned with neat cement after completion of injections 171 OTHER: ❑OTHER: APPROX.BORING DEPTH no greater than 55 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: First mobilization planned for 6/30/15 for soil boring and punch through concrete slab,injections to begin week of 7/6/15 and second set of injections 8/10/15. NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,and al applicable California laws. Signed —T63—J Title/Company Project Geologist/ECM,Inc. Print Name Chris Drabandt Date 6/23/2015 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED S 1 S APPLICATION ACCEPTED BY C DATE ISSGIED ZS/ _/S AREA GROUT INSPECTION BY / FINAL INSPECTION BY� .e- `DApTE�LL � DESTRUCTION INSPECTION Y �� '1��L't2�! DATE ��.Sj/� /�� t✓'r� C%.jx,n�e4��/7 7 r�i '%9 COMMENTS/CONDITIONS: 1L JT) 0�c ` ►11�LjJE ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# ;Lgo S $`ftRX .i 3`(a. - "z o`t6� (,•� b zs'(rs" SR# Z5�3 a9o334D - 7 3'70 f!�-q PR oh s Z-�o36 C-57_) WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-01 5/09/12 FA 0019323 WELL PERMIT APP