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SAN JOAQUIN <br />COUNTY- -- <br />Greatness grows here. <br />Environmental Health Department <br />Job Address 1680W Durham Ferry Road City/State/Zip Tracy, CA 95304 Phone 209-522-4119 <br />Phone 209-522-4119 <br />Cross Street Highway 33 APN 255-100-39 <br />Teranishi Irrevocable Administrative Trust, Sheldon <br />Property Owner* Teranishi <br />Phone 209-522-4119 License# 5023 <br />City/State/Zip Modesto, CA 95351 <br />' • <br />3420 F 209 464-0V38 9 ‘‘Iw 'sjiccAcl,torn <br />Site Mitigation Well Permit APPlication <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 Inspection; <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 />Address PO Box 315 <br />C-57 Contractor V&W Drilling <br />Address 1133 Biackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />Address 1172 Kansas Avenue <br />City/Statealp Bodega Bay, CA 94923 <br />License?* 720904 Phone 209-469-7700 <br />City/State/Zip Galt, CA 95632 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />Date (t (''7(7 <br />DEPARTMENT USE ONLY <br />ZIA Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />/ 6 -51) <br />WP Riewed By <br />fiLt o <br />Work Plan Date fpleA '7 I/ r <br />57 0 C-57 Aulhonzation tor Other to Sign Permit ZWorker's Comp U Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement (21/Lead Agency Approval 0‘FR <br />/1/4k4 Pis-r6 91 rIA—klYVki \ be_ ytc}: <br />t-I 1J 7-o Z_- r1A-c 1,1 /4_14) <br />FA Address FAN FA Name e_e_cr,e1 <br />Z-960 FA PE <br />V-S f) <br />P 8 pfLosi 'NI <br />COMMENTS/CONDITIONS: j c,L4c4 <br />/ (...erl.A.duLk_iv( NA-id <br />DESTRUCTION WORK TO BE PERFORMED: <br />It WELLS TO BE DESTROYED 27" <br />WELL IDs See attached table ol well construction <br />GROUT SPECIFICATIONS Neat cement contaInInq <4% bentonite <br />TREMIE TYPE TO BE USED 0 AUGERS El HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY( <br />(8:1 OVER-BORE DIAMETER of " inches to depth of " feet <br />El PRESSURE GROUT To depth of feel below surface <br />ID EXPLOSIVES From to feel below surface <br />0 MUSHROOM CAP 0 3 feet below surface or leel below surface if >3 feel <br />COMMENTS: "See attached table for well construction details for above information marked with' " " <br />m 27 wells include MW-1 thru MW-3, MW-5, OS-1, OS-2, AS-1 thru AS-6, OW-2, VEW-1 thru VEW-6, MW-2X, MW-101, MW-102, MW- <br />105, SW-102, MW-201 and MW-202. <br />-authorized to complete this application and that the work will be done In accordance with <br />Sa Jrqul • Qrdinance Codes and Standards, and all other applicable California laws. <br />I hereby certify that I a <br />, Title/Compan VP / Ground Zero Analysis, Inc. Signed y <br />Print Name Gregory Stahl <br />WP TYPE PE SC FEE INFd AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Perrnit 7emz„ 3/.3 $152x t 7 61) 'i Y7O V ---- — -- , 14)0 0 37.6 zx <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING El Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING BA <br />TYPE OF CASING. 0 STEEL D PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freetall Depth is 30 Fl) <br />(-1() 1868 elton Avenue Stockton, 14 95205-1 cu9 468 <br />011029-Or 08-01-17 <br />TYPE OF WELUBORING <br />MONITORING <br />EXTRACTION (VapodWaler) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Some. Cannel <br />in OTHER <br />WELU SOIL BORING Ds <br />NUMBER <br /> 0 <br /> 0 <br /> 0 <br />0 <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: _