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RECEIVED EN3/1L EAL Vili. 1/ER 2EN 1TAL2cH0E16 ERM o VI S 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 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: vvww.sicehd.com 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. Address 8020 SOU I H AIRPOR1 WAY City/State/Zip STOCKTON, CA 95206 C-57 Contractor CASCADE DRILLING LP License# 938110 Job Address 8010 SOUTH AIRPORT WAY Cross Street SIIMSON ROHL) Property Owner* CALIFORNIA ARMY NATIONAL GUARD City/State/Zip STOCKTON, CA 95206 Phone APN 177-260-U4 Phone Phone 916-638-1169 Ext 2331 Address 3000 Duluth Si, City/State/Zip West Sacramento GA 95691 Consultant/Sub-Contractor ENDPOINT CONSULTING License# Phone 415 706 8935 Address 1534 PLAZA LANE #243 City/State/Zip BURLINGAME, CA 94010 CONSTRUCTION WORK TO BE PERFORMED: *Note: Ottsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING MONITORING ID EXTRACTION (Vapor/Water) SOIL VAPOR PROBE SOIL BORING 13 INJECTION (hr Spam° Ozonel El OTHER 3 NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS CI HOLLOW STEM BORING DEPTH 35 FEET 0 BOLTED TRAFFIC BOX D STOVE PIPE 0 HAMMER/DRIVEN DIA OF BOREHOLE 8 INCH 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER CONDUCTOR CASING 1=1 Yes 0 No Boring Dia: Casing Dia: Casing Depth GROUT SEAL DEPTH 15 FEET TREMIE TYPE TO BE USED: IN AUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes El No (Note: Maximum Freefall Depth is 30 Ft) i — GROUT SPECIFICATIONS 5 sack mix pt..-' 044-Lk - fl MUD ROTARY PUSH POINT (GP/ CPT) HAND AUGER OTHER: WELU SOIL BORING IDs SB-4, SB-5. SB-6 DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDS GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY( OVER-BORE DIAMETER of inches to depth of feet PRESSURE GROUT To depth of feet below surface ID EXPLOSIVES From to feet below surface 0 MUSHROOM CAP El 3feet below surface or feet below surface if >3 feet COMMENTS: We are going to take samples at 17, 22, 27,32 feet below grade. After reaching the 35 feet depth, the augers will be removed. The bore hole will then be backfill to the surface with 5 sack mix, and top off as need. The last foot will be completed with rapid set concrete and dyed to match existing surface. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Print Name SCOTT POLSTON ilgned :K. Polston DN. al.,. Potston, ou. emal1=Xolz A Polsion.qmall corp. c=US pate2a16., I 16 17.12 ,aentr Title/Company ENDPOINT CONSULTING iNC. Date 11/14/16 DEPARTMENT USE ONLY Application Accepted By: — Grout Inspection By/Dates: Pr -I ) z fiti4 1217//c,, Date Issued: p I- 12 /7/ Destruction Inspection By/Dates: Facility/Site Information FA Name FA Address FA# '_., 0 1 / PR# :-yiA i FA PE WP Reviewed By Work Plan Date Zi..) t. te, 0 C-57 El 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. COMMENTS/CONDITIONS: , SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE REQUEST# INVOICE# Permit 29O5 -,3 t3 $139x 3 A -Y/ 7 . 7.5 -,5 _ Aff/C A 0 076, • r I tis'e. Z96 5 /513 .5k 0040Pi 4.c k$tec-, EHD 29-01 10-26-2015 Site Mitigation Well Permit Application R 0076055