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SAN JOA01. N SEP 1 2fl'g nvironme[ ii Health Department <br />e.40 <br />COMMENTS: See attached table for well c struction details for some of the above information. <br />I hereby certify that I <br />San Joaq <br />Signed <br />Print NameGregory Stahl <br />o ed to complete this application and that the work will be done in accordance with <br />rd'nance Codes and Standards, and all other applicable California laws. <br />Title/Company VP / Ground Zero Analysis, Inc. <br />Date 9/13/2017 <br />aut <br />- COUNTY <br />ENVIRONMENTAL HEF.0 <br />PERMIT/SERVICES <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 />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 />140 Ft SE from Corner of HWY 33 & Durham Ferry Road <br />Job Address Intersecton City/State/Zip Tracy, CA Phone 209-942-6018 <br />Cross Street Highway 33 <br />St of Cal Department of Transportation — Paul <br />Property Owner* Cavanaugh <br />Address 1976 E. Dr. Martin Luther King Jr., Blvd <br />C-57 Contractor V&W Drilling <br />APN Cal Trans Right of Way <br />Phone 209-942-6018 <br />City/State/Zip Stockton, CA 95205 <br />License# 720904 Phone 209-469-7700 <br />Address 1133 Blackhurst City/State/Zip Galt, CA 95632 <br /> <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. License# 5023 Phone 209-522-4119 <br />Address 1172 Kansas Avenue <br /> <br />City/State/Zip o st. A95351 <br />TYPE OF WELL/BORING NUMBER <br />12 MONITORING <br />EXTRACTION Vapor/Water) <br />SOIL VAPOR PROBE 0 <br />El SOIL BORING <br />INJECTION (Air Sparse Ozone) 0 <br />OTHER <br />WELL/ SOIL BORING IDs <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells R i V <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATI <br />HOLLOW STEM BORING DEPTH <br />HAMMER/DRIVEN DIA. OF BOREHOLE <br />MUD ROTARY CASING THICKNESS <br /> 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />ss sreements or Encroachment Permits <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING <br />Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER <br /> <br />GROUT SEAL DEPTH <br /> <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER: GROUT SEAL PUMP <br /> <br />0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFIC ONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />It WELLS TO BE DESTROYED 1 <br />WELL IDs MW-4 <br />GROUT SPECIFICATIONS Neat cement containin <4% benton <br />TREMIE TYPE TO BE USED 0 AUGERS El HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY' <br />Eg OVER-BORE DIAMETER of 10 inches to depth of 22 feet <br />PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <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 <br />, <br />FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 0-57 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 $152x <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 08-01-17 Site Mitigation Well Permit Application