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/0- <br />(.? <br />oi) \ ) COUNTY <br />, <br /> s?-/ Greatness arnwc h ,,re <br />Environme..,a1 Health Department SAN JOAOLA <br />C-57 Contractor V&W Drilling <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 28 *** <br />IRENE TYPE TO BE USED D AUGERS D HOSE El PIPE <br />Address PO Box 315 City/State/Zip Bodega B •492 <br />License4 720904 Phone 209-469-7700 <br />City/State Address 1172 Kansas Avenue <br />0 OVER-BORE <br />IZ PRESSURE GROUT <br />1:1 EXPLOSIVES <br />0 MUSHROOM CAP <br />DIAMETER of .* inches to depth of ** feet <br />To depth of ** feet below surface <br />From _ to feet below surface <br />El 3 feet below surface or ** feet below surface if >3 feet <br />Address 1133 Blackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Requ <br />desto, C .)95351 <br />CC s gr ents or Encroachment Permits <br />City/StateNalt, C 56 <br />Licensett 502 Phone 209-522-4119 <br />TYPE OF WELL/BORING NUMBER <br />MONITORING 0 <br />EXTRACTION (Vapor/Water) 0 <br />ID SOIL VAPOR PROBE 0 <br />SOIL BORING <br />INJECTION (Air Some Ozone) 0 <br />OTHER 0 <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />LIED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />E OF CASING: 0 STEEL 0 PVC 0 OTHER <br />es 0 No _/Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />No (Note: Maximum Freefall Depth is 30 Ft) <br />CONSTRUCTION SPEC1FICATIO <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING\) <br />GRO T SEAL DEPTH <br />T SEA MPED? <br />ROUTS FICAT <br />WELL Ds See attached table of well construction <br />GROUT SPECIFICATIONS Neat cement containin <4% bentonite <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />San Jo/Tin C <br />‘Vi <br />Signed <br />Print Name Gregory Stahl <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />-o <br />= 3 ' Fr <br />m 7:3 <br />3 a: <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe ./\ rj4 F <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin Co 4\Well Standarg. <br />48 Hours Advance Notice Required For All Inspections <br />Job Address 1680W Durham Ferry Road <br />Cross Street Highway 33 <br />City/State/Zip Tracy, CA 95304 Qho e 209-522-4119 <br />APN 255-100-39 <br />Teranishi Irrevocable Administrative Trust, Sheldon <br />Property Owner* Teranishi Phone 209-522-4119 <br />COMMENTS: ** See attached table for well construction details for above information marked with " ** " <br />*** 28 wells include MW-1 thru MW-5, MW-8, OS-1/OS-2, AS-1 thru AS-6, OW-2, VEW-1 thru VEW-6, MW-2x, MW-101, MW-102, MW-105, SW- <br />102, MW-201 and MW-202. <br />I h reby certify that I am ay h zed to complete this application and that the work will be done in accordance with <br />nance Codes and Standards, and all other applicable California laws. <br />Title/Company( VP / Gr und Zero Analysis, Inc. 2,w <br />T - r*-7 Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's 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 Z,40Z---&/ :. $152x S.— <br />/. '7 6 0 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com <br />EFID 29-01 08-01-17 Site Mitigation Well Permit Application