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" SAN JOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT �. 1868 Hazelton Avenue, Stockton, CA 95205-6232 OCT 14 2016 ..c P.. T 1 h 209 468 3420 F 209 468 3433 W b h 7-1 <iFORN` a ep one. ( ) - ax. ( ) - e . www.slce d.com ENVIRONMENTAL HEALTH SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMIT/SERVICES 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 ROAD APN 177-260-29 7TZ(p6 F— f --*- r..- +(-Y p44,ce.( Property OwneP CALIFORNIA ARMY NATIONAL GUARD Phone Address 8010 SOUTH AIRPORT WAY C-57 Contractor CASCADE DRILLING LP Address 3000 Duluth St, ConsultantJSub-Contractor ENDPOINT CONSULTING Address 1534 PLAZA LANE #243 City/State/Zip STOCKTON, CA 95206 License# 938110 City/Stats/Zip West Sacramento CA 95691 License# City/State/Zip BURLINGAME, CA 94010 Phone 916-638-1169 Ext 2331 Phone 415.706.8935 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH 35 FEET ® BOLTED TRAFFIC BOX ❑ STOVE PIPE ® EXTRACTION (Vapor/Water) 6 ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 8 INCH ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCH 40 TYPE OF CASING: N STEEL ® PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ® INJECTION (Air Soarae. Ozone 6 ❑ HAND AUGER GROUT SEAL DEPTH 15 FEET TREMIE TYPE TO BE USED: E AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs IW -1, IW -2, IW -3, IW -4, IW-5,IW-6 GROUT SPECIFICATIONS HIGH TEMP RESISTANT GROUT "SEE ATTACKED MSDS" EW -1, EW -2, EW -3, EW4, EW -5, EW -6 DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS PIPE 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 ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface THE STEAM INJECTION WELL (IW -1 TO IW -6) WILL USE STAINLESS STEEL CASINGS, WHILE THE EXTRACTION WELLS (EW -1, TO EW -6) WILL USE PVC CASING here WlfyntI amauthorized to complete this application and that the work will be done in accortlance with uin County Ordinance Codes and Standards, and all other applicable Calffomia laws. Signed ° " Title/Company ENDPOINT CONSULTING iNC. Print Name SCOTT POLSTON Date 10/10/16 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: DEPARTMENT USE ONLY 'j6 Date Issued: /v/Z-f l API. FA Name FA Address FA# Do / p Z �// PRq b y ► -3& i FA PE WP Reviewed By [� , / �%vG// '�^ rli�i� Work Plan Date ❑ C-57 Eff57 A thonzation for Other to Sign Permit Worker's Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement �ead Agency Approval 24FR COMMENTS/CONDITIONS: l/SG &f HCII, `-e-,AWev.*vse- jf- `'r a0pIY✓e ' SR TYPE I PE I SC I FEE INFO JAMT REMITTED1 CHECK# RECV'D BY DATE SERVICE REQUESTS INVOICE# Permit 12901 1-3(3 $139 x 51 0 /,i�- I7�3y C.�r� rRoU7l�o 55 2903 523 y/7 � �/7 7537 CA/7'/C- -5W0074651 EHD 29-01 10-26-2015 Site Mitigation Well Permit Application