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TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam, Ozone) <br />OTHER <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> o MUD ROTARY <br />3 NJ PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />WELL/ SOIL BORING IDs SB-4, SB-5, SB-6 <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, and the San Joaquin County Well Standards. <br />Job Address 8010 Airport Way city/state/zip Stockton, CA 95206 Phone <br />Cross Street Stimson Street APN <br />Property Owner* California Army National Guard (LTC Belinda May) Phone 916-854-1483 <br />Address 3900 Roseville Road city/state/zip North Highlands, CA 95660 <br />C-57 Contractor Penecore Drilling License# 906899 exp 11/30/17 Phone 530-661-3600 <br />Address 220 N East Street City/State/Zip Woodland, CA 95776 <br />Consultant/Sub-Contractor ECM Consultants License# Phone <br />City/State/Zip Costa Mesa, CA 92626 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />Address 3525 Hyland Ave, Suite 200 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 35 bgs 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 3.2 inches 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL El PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: EI AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? [X Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Bentonite 5%, Portland Cement 95% <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS EJ HOSE CI PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />CI OVER-BORE DIAMETER of inches to depth of feet <br />CI PRESSURE GROUT To depth of feet below surface <br />CI EXPLOSIVES From to feet below surface <br />CI MUSHROOM CAP CI 3 feet below surface or feet below surface if >3 feet <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 />47 -2-- <br /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Project Manager / ECM <br />Print Name Chris Drabandt Date 7/7/2016 <br /> <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: / <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />ir-17,3"er#1 <br />04)(2i3or\ <br />Date Issued: <br />7/2 0// te 72/lli <br /> <br />FA Name FA Address FA# 00 ) g 29) PR# 6524,91 <br />FA PE WP Reviewed By /04.01,46, foe/ Work Plan Date , - o i .71,ly 26 4 le <br />0 C-57 (2157 Authorization for Other to Sign Permit 2Sorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement fLead Agency Approval [fef(R <br />COMMENTS/CONDITIONS: LisLL -6-ekli ;-6 ij,t)e -to eta? (“e. top4-1.-c) Cetoe.i.Lt/ f-c,-J 1—, <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan Z*)3 523 --5D 3 9 6 <br />.?. ff e, <br />1298IZ 7/"/4' ,5 :/.6 075253 <br />Permit 2905 313 $130 x 3 4 3y a IzyglZ 1/1/1 5/ 00 752-9 <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />Signed