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SAN„JOAQUIN <br />LD.1110 COUNTY <br />cslar", Greatness grows here. <br />Environmental Health Department <br />EC <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION DEC 1 5 2017 <br />For Wells and Borings Used for Contaminant Investigations and Remediaticim -GriVIRONMENT HEALTH <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 Stockton, CA 95206 Phone <br />Cross Street Stimson Street APN 177-260-04 <br />Property Owner* California Army National Guard (Brian Pierskalla) Phone 916-854-1487 <br />Address 3900 Roseville Road <br />Address <br />C-57 Contractor t)t-igt.l.d rt T>n 1 1.-110) .1.114 <br />220 N East Street <br />Consultant/Sub-Contractor ECM Consultants <br />City/State/Zip North Highlands, CA 95660 <br />License# 906899 exp 11/30/18 Phone <br />City/State/Zip Woodland, CA 95776 <br />License# Phone <br />City/State/Zip Costa Mesa, CA 92626 Address 3525 Hyland Ave, Suite 200 <br />530-661-3600 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam Ozone). <br />OTHER <br />WELL/ SOIL BORING IDs <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />13 HAMMER/DRIVEN DIA. OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of 10 inches to depth of 358.25 feet <br /> <br />WELL IDs 1W-1, IW-2, IW-3, IW-4, IW-5, IW-6, EW-1, EW-2, EW-3, EW-4, 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS Bentonite 5%, Portland Cement 95% EW-5, EW-6Ljr" EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED 12I AUGERS 0 HOSE 0 PIPE <br /> <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <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 Title/Company Project Geologist / ECM <br />Chris Drabandt Date 12/13/2017 Print Name <br />DEPARTME T USE ONLY <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: L.1 %/hal I •,-1-4 IT-NJ L -X ‘I‘i b Tito L--)( '41 <br />Facility/Site Information cD • I.' X — <br />FA Name C.A0-fr•• Sk:42., 4_,,. 444 t FA Address . <br />jct.'', 0 Alfe.ft %del PR# ,S FA# <br />/ <br />00 1,11 co <br />— <br />FA PE (9_G (2 5 WP Reviewed By L -)( Work Plan Date to i <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit ,),,C10"2, 313 $152x Vi e0 01-11W <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 OB-01-17 <br />LCAO'i3 4145%o IrL tiiiit 1 5i..oi scR <br />Site Mitigation Well Permit Application