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1` 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 COVIRONMENT 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 Address 3900 Roseville Road City/State/Zip North Highlands, CA 95660 C-57 Contractor ?t_d1Ge.+rt lnr,Il,A TrMC License# 906899 exp 11/30/18 Phone Address 220 N East Street City/State/Zip Consultant/Sub-Contractor ECM Consultants License# Woodland, CA 95776 Address 3525 Hyland Ave, Suite 200 City/State/Zip Costa Mesa, CA 92626 Phone 916-854-1487 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits 530-661-3600 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 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 Iwl 19 f Q-11 �T-W -30 , T,) L X I\� � {�`� ��-2s . L Facilit /Site Information I s 0 ".J -2- e" -k • L \ \ \ FA Name FA Address FA# PR# FA PE WP Reviewed By_ 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 WELL INVOICE# Permit �;c1v2 3f,3 $152x 1('0 (Z3�1 �/ J {ZI'zr 0Q©V-I1 .5 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com 4 EHD 29-01 Ota l -17i Site Mitigation Well Permit Application W aqo� SZ -S 1'SLX`3 tob 4 1t1 5CLC