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SAN JOAQUIN COUNTY �''1V k` rr z ENVIRONMENTAL HEALTH DEPARTMENT a <� NOV 1 1 2016 `• / 1868 Hazelton Avenue, Stockton, CA 95205-6232 EI�VIR� �l`�,RN'' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sucehd.com taIEN'1AL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICATION ERNi1TISERWCES For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 SOUTH AIRPORT WAY City/State/Zip STOCKTON, CA 95206 Phone Cross Street STIMSON RUAU APN 177-260-04 Property Owner* CALIFORNIA ARMY NATIONAL GUARD Address 8020 SOU I H AIRPOR t WAY C-57 Contractor CASCADE DRILLING LP Address 3000 Duluth Si, ConsultanUSub-Contractor ENDPOINT CONSULTING Address 1534 PLAZA LANE #243 City/State/Zip STOCKTON, CA 95206 License# 938110 City/State/Zip West Sacramento CA 95691 License# City/State/Zip BURLINGAME, CA 94010 Phone Phone 916-638-1169 Ext 2331 Phone 415.706.8935 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite Bonngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING ❑ MONITORING ❑ EXTRACTION (Vapor/Water) ❑ SOIL VAPOR PROBE ® SOIL BORING ❑ INJECTION (Air Sparge, Ozorel ❑ OTHER _ WELL/ SOIL BORING IDs SB - NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 8 HOLLOW STEM BORING DEPTH 35 FEET ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 8 INCH ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER 3 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth. ❑ HAND AUGER GROUT SEAL DEPTH 15 FEET TREMIE TYPE TO BE USED: ® AUGERS ❑ HOSE ❑ PIPE ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Fl) �— j SB -5. SB -6 GROUT SPECIFICATIONS 5 sack mix f G f (ctc�C) ( E �k� h eA DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS DESTRUCTION METHOD: (CHECK ALL THAT APPLY) ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface rREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet 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 herebv certifv that 1 am authorized to complete this aoolication and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. rM+M *5^'a M Smn Pohm Signed u° °^ °' Title/Company ENDPOINT CONSULTING INC. Print Name SCOTT POLSTON Date DEPARTMENT USE ONLY Date Issued: Application Accepted By: �- Grout Inspection By/Dates: ) /'j'- Z i f'Y ? Nr i "/7 14 Destruction Inspection By/Dates: Xa ility/Sita Infnrmntinn FA Name FA Address FA# Z� PR# FA PE WP Reviewed By / G Work Plan Date J tit ZU r 7 ❑ C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS: P w/" pt"',-rIcw'c, .T yiCX SR TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE SERVICE REQUEST# INVOICE# Permit 290j ,1,3 $139x 3 Yy/% -/53% Use 290 3 j 543 5,2 00 700 57'! Al- yi�csKe. EHD 29-01 10-26-2015 Site Mitigation Well Permit Application Sk0L)766955