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=aD(A, Environmental Health Department <br />0°Z SAN:JOAQUING <br />" COUNTY <br />cc(Foa�'�P, grows her•- <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 />48 Hours Advance Notice Required For All Inspections <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 St <br />Cross Street Stimson Street APN 177 -260 - <br />Property Owner" California Army National Guard (Brian Pierskalla) <br />Address 3900 Rpeville Road City/State/Zip N <br />C-57 Contractor <br />Address 220 N East <br />Consultant/Sub-Contractor <br />Address 3525 Hvlan( <br />Consultants <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite <br />RING <br />TYPE OF WELLMONITORING <br />NUMBER INSTALLATION TYP_ <br />❑ MONITORING <br />HOLLOW STEM <br />❑ HOLLOW STEM <br />❑ EXTRACTION (VaporMater) <br />❑ HAMMERIDRIVEN <br />❑ SOIL VAPOR PROBE <br />❑ MUD ROTARY <br />❑ SOIL BORING <br />❑ PUSH POINT (GP/ CPT) <br />❑ INJECTION (Airsoarae. ozone) <br />❑ HAND AUGER <br />❑ OTHER <br />❑ OTHER <br />WELU SOIL BORING IDs <br />COMMENTS/CONDITIONS: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs IW -1, IW -2, IW -3, IW -4, IW -5, IW -6, EW -1, EW -2, <br />GROUT SPECIFICATIONS Bentonite 5%, Portland Ceme t 95% <br />TREMIE TYPE TO BE USED ® AUGERS ❑ HOSE W PIPE <br />License# ( <br />City/State/Zip <br />License# <br />CA 9-506 Phone <br />Phone 916-854-1487 <br />CA 95660 <br />11/30/18 Phone 530-661-3600 <br />A, CA 95776 <br />Costa Mesa, CA 92626 <br />Phone <br />Require Access Agreements or Encroachment Permits <br />BORI/THICKSS <br />❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE <br />DIA. ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />G <br />TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE <br />GRO? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />Sp EXPLOSIVES From to feet below surface <br />fl USHROOM CAP fl 3 feet below surface or feet below surface if>3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />�% San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed U11 I Title/Co any Project Geologist / ECM <br />Print Name Chris Drabandt Date /13/2017 <br />DEPARTMENT USE ONL <br />Application Accepted By:_ <br />Grout Inspection By/Dates: <br />Destruction Inspection By/ <br />Far_I11tulSifa Infnrmnti <br />Date Issued: <br />FA Name <br />FA Address <br />FA� <br />PR# <br />FA PE <br />/ <br />WP Reviewed By <br />Work Plan Date <br />❑ G57 b G57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />JAMT REMITTED <br />CHECK# <br />RECV-D BY <br />DATE <br />WELL PERMIT# INVOICE# <br />Permit <br />$152 x <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />EHD 29-0108-01-17 Site Mitigation Well Permit Application <br />