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ultv SANAOAQUIN Environmental Health Department COUNTY �� C�. �c:9crFoaa�� Grentnrss crows here. l� SITE MITIGATION WELL & BORING PERMIT APPLICATION DEC 15 2011 For Wells and Borings Used for Contaminant Investigations and Rem ed i ati CLtVIRONMENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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. Job Address 8010 Airport Way City/State/Zip Stockton, CA 95206 Phone Cross Street Stimson Street APN 177-260-04 Property Owner" California Army National Guard (Brian Pierskalla) Phone 916-854-1487 Address 3900 Roseville Road City/State/Zip North Highlands,CA 95660 C-57 Contractor?t_d1G�drt ��1� . �rMC License# 906899 exp 11/30/18 Phone 530-661-3600 Address 220 N East Street City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor ECM Consultants License# Phone Address 3525 Hyland Ave,Suite 200 City/State/Zip Costa Mesa,CA 92626 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ®OVER-BORE DIAMETER of 10 inches to depth of 35&25 feet WELL IDs IW-I,IW-2,IW-3,IW-4,IW-5,IW-6,EW-1,EW-2,EW-3,EW-4, ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Bentonite 5%,Portland Cement 95% -5° -6❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that 1 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 V"7 I/�— Title/Company Project Geologist/ECM Print Name Chris Drabandt Date 12/13/2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: I Z /Z y / -7 Grout Inspection By/Dates: Destruction Inspection By/Dates: L-1 1 f Iw 119 VQ-4 T-W-10,T,) L 2s . L tt Facilit /Site Information ��✓-C� �� 0 n.J—L j -S e,,-k • L \ \ \ FA Name FA Address FA# PR# i;,&y OU `{ C't; ©� FA PE WP Reviewed By L_ Work Plan Date ❑G57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELrL,,PERMIT# INVOICE# Permit dc1v 2 3i3 $152 x 4�1 (�0 I$z3w� fi� {Z�'zr 1 0 P©Ch-7l .5 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com 4 EHD 29-01 OMl-17 . Site Mitigation Well Permit Application W aqo� SZ-S 1'SLX`3 L00 114 L-X li-gW01