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"r `z SANAOAQUIN Environmental Health Department �1 COUNTY ° Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION AUG 31 MCI For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours 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 1819 South Argonaut Street City/State/Zip Stockton,CA 95206 Phone None Cross Street Irene APN Property Owner* John Taylor Fertilizer c/o Eric Jenks Phone 510-236-6282 Address P.O.Box 511 City/State/Zip Yuba City,CA 95991 C-57 Contractor Directed Technologies Drilling License# 720357 Phone 800-239-5950 Address 100 Rolling Ridge Drive City/State/Zip Bellefonte/Pennsylvania/16823 Cons ultant/Sub-ContractorGeosyntec Consultants, Inc. License# Phone 916-637-8048 Rancho Address 3043 Gold Cana Drive,Suite 100 City/State/Zip Cordova/California/95670 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 20 to 25 feet bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 6 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ® OTHER HDPE ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ® INJECTION(Air Sparge,Ozone) 2 ❑ 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) For injection of emulsified WELL/SOIL BORING IDs IW-G,IW-H vegetable oil GROUT SPECIFICATIONS Grout mixed to SJCEHD specification and tremmied into the borehole. DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #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 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 o°" Title/Company CM/narected TP(-hnnlnalP.S Drilling Print Name James Doesburg Date 8/30/2017 ARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name r FA Address S r FA# � 1 PR# '.-.c) FA PE `]y�6 ((� WP eviewed By "L__ p�__ Work Plan Date 7D J &C-57 [I Authorization for Other to Sign Permit orkers Comp ❑workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ead gency pproval R<FR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# �e�C 'oto r 12;,i '3 .L,� �s v 3�� 4 �0� 7 7�7 I 1868 E. Hazelton Avenue Stockton, Californ a 94005 T__209 4 8-3420 209 64-01 8 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application W se n '7-7'7'7 D