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r-vok cr. if 209 579*— 9/9:if <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <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 />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, arid the San Joaquin County Well Standards. <br />Job Address 8010 Airport Way <br />Cross street Stimson Street <br />Property Owner* California Army National Guard <br />cityisteterzio Stockton, CA 95206 Phone <br /> APN <br />(LTC Belinda May) Phone 916-854-1483 <br />Address 3900 Roseville Road City/State/Zip North Highlands, CA 95660 <br />C-S7 Contractor Penecore Drilling Licenses 906899 exp 11/30/17 <br />Address 220 N East Street city/state/zip Woodland, CA 95776 <br />Phone 530-661-3600 <br />Phone Consultant/Sub-Contractor ECM Consultants LIcense# <br />City/State/Zip Costa Mesa, CA 92626 Address 3525 Hyland Ave, Suite 200 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />CI MONITORING 0 HOLLOW STEM BORING DEPTH 45 bgs 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 EXTRACTION (VapcdWateg 0 HAMMER/DRIVEN DIA. OF BOREHOLE 3.2 inaies MULTIPLE CASINGS MULT1-LEVEL WELL CASING DIA <br />0 SOIL VAPOR PROW 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 SOIL BORING El PUSH POINT iGP/ CPT) CONDUCTOR CASING 0 Yes 0 No BotLng Die Casrig 0ia Casing Depth: <br />INJEOPON tAt, Sure, cant.til —23 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE Eta PIPE <br />o OTHER 0 OTHER: GROUT SEAL PUMPED? Cg Yes 0 No (Note Maximum Rectal Depth is 30 Fl) <br />WELL+ SOIL BORING tDs I-65 through 1-87 GROUT SPECIFICATIONS Bentonite 5%, Portland Cement 95% <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL Ds <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feel <br />0 PRESSURE GROUT To depth of <br />From <br />feet below surface <br />0 EXPLOSIVES to feet beicw surface <br />0 MUSHROOM CAP (J 3 feet below surface or feet below surface d >3 feet <br />COMMENTS: <br />hereby certify that I am atitttorizettto complete this application and that the work will be done in accordance with <br />SistJoaquin,County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 147Title/Company Project Geologist / ECM <br />Print Name Chris Drabandt Date 11/16/2016 <br />Application Accepted By: 2: <br />Grout Inspection By/Dates: <br />DEPARTMENT USE ONLY <br /> <br />/Z/2A <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Sit. Information <br />FA Name I FA Address 1 I FA# cc i s-34 3 [ PR# e 5 Z. 7 LI 34_ <br />FA PE WP Reviewed By :-.'7 ,Z,/ez, , I Work Plan Date <br />0 C-57 CI C-57Auticrizatim for Other to Sign Permit priVaker's Comp 0 Wolter's Conp Waiver 0 Encroachment Permit 0 Access Agreement Ci Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: or.,..,,,,t- .b.„-, hji 4...,,,i-41.1c,--ria„,,Jr•euterr_i, ble&-f ao l)... ‘'' (')1 -ft" Cir4.444'gj L.LA r tt ple-LL. <br />SR TYPE PE SC 1 FEE INFO 1AMT REMITTED CHECKS RECV'D BY DATE SERVICE REQUESTS INVOICES <br />Work Plan 2 90 3 <br />I <br />- / 7 ?-41/7 — 1 i52.) 1 rAffie /27/V/ 9A ec 74 zi / I <br />Permit 2 (.." 5 i,s, x ,--7, l''Y'17 — 404 5le ev 7i.2 i i z__ <br />Site Mitigation Well Permit Application El-ID 29-01 6-23-2015