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rw SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APN 143-430-61 Cross Street North Shasta Ave. Phone (209) 946-0233 Property Owner* Diesel Performance Inc. C-57 Contractor TEG License# 706568 Phone (916) 853-8010 City/State/Zip Modesto, CA 95351 Address 1117 Lone Palm Avenue, Ste. 201B CONSTRUCTION SPECIFICATIONS BORING DEPTH 20 ft. Cl BOLTED TRAFFIC BOX Cl STOVE PIPE DIA. OF BOREHOLE 2 in. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: Cl STEEL Cl PVC Cl OTHER TYPE OF WELL/BORING NUMBER INSTALLATION TYPE Cl MONITORING Cl HOLLOW STEM Cl EXTRACTION (Vapor/Water) Cl HAMMEPJDRIVEN 1-JT SOIL VAPOR PROBE 0 MUD ROTARY IX SOIL BORING 2 IM PUSH POINT (GP/ CPT) Cl INJECTION Or Sparue: Ozonel Cl HAND AUGER 0 OTHER Cl OTHER: WELU SOIL BORING IDs SB-105. SB-106 CONDUCTOR CASING Cl Yes IZI No Boring Dia: Casing Dia: Casing Depth: GROUT SEAL DEPTH 20 ft. TREMIE TYPE TO BE USED: Cl AUGERS Cl HOSE PIPE GROUT SEAL PUMPED? Cl Yes IZ1 No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS Neat Cement Signed COMMENTS: The soil vapor probe will be installed first to approximately 5 feet bgs and after vapor sample collected and associated tubing removed, the soil boring will be advanced through the same bore hole to approximately 20 feet bgs. 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. Title/Company a.- /,-"Dre7-1-1 trcA) CAL. fro re it-,(4- C Print Name MArtlf._ Date 5-5 - o iros Co/L4)1cl "Se_co -n-) cl \-0 e -z"1.057 5z3 13`1,A 3 EHD 29-01 10-26-2015 Site Mitigation Well Permit Application 1868 HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.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 2804 East Fremont Street City/State/Zip Stockton, CA 95205 Phone (209) 946-0233 Address 2804 East Fremont Street City/State/ZIP Stockton, CA 95205 Address 11350 Monier Place Consultant/Sub-Contractor ATC Group Services, LLC City/State/Zip Rancho Cordova, CA 95742 LIcense# Phone (209) 579-2221 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offslte Borings/Wells Require Access Agreements or Encroachment Permits DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED El AUGERS Ci HOSE El PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) E] OVER-BORE DIAMETER of inches to depth of feet 0 PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface cl MUSHROOM CAP ci 3 feet below surface or feet below surface if >3 feet DEP RTMENT USE ONLY Date I sued: Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: FA Name \.,,-s,c ( P.e.r.ro„- os.....n.c._ r,,,.... FA Address 24°4 " CY.(11.1""‘A" FA# oo 2_,‘..k ez 6 PR# 0 c .11 1 1 1 FA PE 2-A Sill WP Reviewed By 1, -Y. Work Plan Date 5.71S12-01/ Agency Approval 0 MFR Cl C-57 0 C-57 Authorization for Other to Sign Permit Cl Worker's Comp Cl Worker's Comp Waiver Cl Encroachment Permit Cl Access Agreement 0 Lead COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit 7_5) c '‘ 3 13 $139x 2 4 D•ig o'nela; L -)< (io(v))i ) gr-.0o-v -rtelo