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U'"'..c SAN JOAQUIN COUNTY -r� ENVIRONMENTAL HEALTH DEPARTMENT • '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 cq<<FOR�:P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.socehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION 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 Airport Way City/State/Zip Stockton, CA 95206 Phone Cross Street Stimson Street APN Property Owner' California Army National Guard (LTC Belinda May) Phone Address 3900 Roseville Road City/State/Zip North Highlands, CA 95660 C-57 Contractor Penecore Drilling License# 906899 exp 11/30/17 Phone Address 220 N East Street City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor ECM Consultants License# Address 3525 Hyland Ave, Suite 200 City/State/Zip Costa Mesa, CA 92626 Phone 916-854-1483 530-661-3600 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 35' bas ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 3.2 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING _3 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, 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/SOILBORING IDs SB -4, SB -5, SB -6 GROUT SPECIFICATIONS Bentonite 5%, Portland Cement 95% 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 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 I 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 14 I/� Title/Company Project Manager / ECM Print Name Chris Drabandt Date 7/7/2016 DEPARTMENT USE ONLY Application Accepted By: ii Pi o,= Date Issued: 7/1•J1j6 Grout Inspection By/Dates: Alal 7T2 p / 7 u /� Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address I IFA# I 00j8Z91PR# Z6 9 FA PE I WP Reviewed By /r . f,r4 1 Work Plan Date - c i Tvr Z,/ 4 ❑ C-57 C-57 Authorization for Other to Sign Permit orker's Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement EfLead Agency Approval FR COMMENTS/CONDITIONS: �/S�_ - ru.,-A�'c �,lpe -to euc� l4ct ceWtpl,i.tPoJT, SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Z�03 523' !C39a ''390 5:U07_525_9 Permit 2 %t � 313 $130x 3 4,3y0 091 Z _7 1 t 1� 51Z0073_2-5_9 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application