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SAN _J Q A Q U I N Environmental Health Department COUNTY 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 48 Flours Advance Notice Required For All Inspections 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 1021 Industrial Dr,944 Zephyr St,and 1010 Zephyr St City/State/Zip Stockton,CA,95206 Phone Cross Street S Airport Way APN 177-280-12, 177-280-13,and 177-280-14 Property Owner` Ingredion Incorporated Phone (209)547-8251 Address 1021 Industrial Dr City/State/Zip Stockton, CA 95206 C-57 Contractor Penecore Drilling License# 906899 Phone (530)661-3600 Address 220 North East Street City/State/Zip Woodland,CA 95776 ConsultantiSub-Contractor Ramboll License# Phone 510-420-2503 Address 2200 Powell Street.Suite 700 City/State/Zip Emeryville,CA 94608 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 40 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapocNVater) El HAMMER/DRIVEN DIA OF BOREHOLE 2.5 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING ❑ 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 ❑ OTHERGROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs SBOt thrcugh S310 GROUT SPECIFICATIONS i'•rl( DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TRENIIE TYPE TO BE USED ❑AUGERS ❑HOSE [-]PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet COMMENTS: j4iereby 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 applicabl California laws. Signed Title/Company II(1 �-U Print NayrSe UC e(1 Date �- EPARTMENT USE ONLY Application Accepted By: Date Issued: 1 r/ Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information A h 7 FA Name �n redI6r FA Address /02! l✓1�-!T(f FA# Qt/(� X23 PR �(�# Q ✓ f �-w FA PE Q50 WP Reviewed By Work Plan Date F p qC-57 :-57 Authori lzation for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COM ENTS/CONDITIONS:SuL ,ro 1r SJC— kkl --eAs t3,-4 �It� s -e�" �c�� "-��1 s vol s.�6•� t�;ll fie. b<l/e�! Q-E c�tr✓.s°.>r� r�-f� . WP TYPE PE sC FEE INFO AMT REMITTED CHECK#I REC`VgDB]Y DATE WELL 1PE'R1MIT# INVOICE# Permit 2q 13 $152. `'�-'j 2C C ll �rW (0 /P 120 S 6pO `j 'g1 1 1868 E. Hazelton Avenue Stockton California 95205 Z09 468-3420 1 F 209 464- 138 www.sjcehd.com EHD 29-01 OMl-17 site Mifigatlon Wei Permit Application