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QUSN <br />SANIJOAQUIN <br />COU NTY— \ <br />Greatness grows here. <br />Environmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 8010 Airport Way City/State/Zip Stockton, CA 9 16 Phone <br />Cross Street Stimson Street <br />Property Owner California Army National Guard (Brian Pierskalla) Phone <br />Address 3900 'e eville Road City/State/Zip No Highlands, CA 95660 <br />C-57 Contractor License# 9068 exp 11/30/18 Phone <br />Address 220 N East St et <br />Consultant/Sub-Contractor E Consultants <br />Address 3525 Hyland Ave, S 'te 200 <br />APN 177-260-04 <br />916-854-1487 <br />530-661-3600 <br />City/State/Zip <br /> oodland, CA 95776 <br />License# <br /> <br />Phone <br />City/Sta IZip Costa Mesa, CA 92626 <br />CONSTRUCTION WORK TO BE PER RMED: *Note: Offsite Borings/We Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATiON TYPE CONSTRUCTION SP FICATIONS <br />MONITORING 0 HOLLOW STEM <br /> <br />BORING DEPTH <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br /> <br />DIA. OF BOREHO <br />SOIL VAPOR PROBE 0 MUD ROTARY <br /> <br />CASING THICK <br />SOIL BORING 0 PUSH POINT (GP/ CPT) ONDUCTO <br />CI INJECTION (I.Jr Spam Ozone' 0 HAND AUGER G UT S <br />OTHER 0 OTHER: <br />WELL/SOIL BORING IDs <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SS TYPE OF CASING: 0 STEEL DPVC 0 OTHER <br />GRO <br />GRO <br /> <br />CASING 0 NI* 0 No Boring Dia: Casing Dia: Casing Depth: <br /> <br />L DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />EAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />PECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs 1W-1, IW-2, IW-3, IW-4, IW-5, IW-6, EW-I, E -2, EW-3, EW-4, <br />TREMIE TYPE TO BE USED g AUGERS 0 HOSE PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY). <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />USHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />GROUT SPECIFICATIONS Bentonite 5%, Portland Ceme t 95% EW-5, EW-6 <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print Name Chris Drabandt <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/ ates: <br />Facility/Site lnformati <br /> <br />Date Issued: <br /> <br />FA Name FA Address PR# <br />FA PE 7 <br />WP Reviewed By Work Plan Date <br />0 C-57 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjoehd.conn <br />El-ID 29-01 08-01-17 Site Mitigation Well Permit Application <br />-12 <br /> <br />Title/Co <br />Date <br />any Project Geologist / ECM <br /> <br />/13/2017