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<br />SAN JOAO' <br /> <br />Environmt ,01 Health Department <br /> <br />COUNTY <br />Greatness grows here. <br /> <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 />Job Address 1680W Durham Ferry Road City/State/Zip Tracy, CA 95304 Phone 209-522-4119 <br />Cross Street Highway 33 APN 255-100-39 <br />Teranishi Irrevocable Administrative Trust, Sheldon <br />Property Owner* Teranishi Phone 209-522-4119 <br />Address PO Box 315 <br />C-57 Contractor V&W Drilling <br />City/State/Zip Bodega Bay, CA 94923 <br />License# 720904 Phone 209-469-7700 <br />Address 1133 Blackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />Address 1172 Kansas Avenue <br />City/State/Zip Galt, CA 95632 <br />License# 5023 <br /> <br />Phone 209-522-4119 <br />City/State/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam, Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE <br /> 0 MUD ROTARY CASING THICKNESS <br /> 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING <br /> El HAND AUGER GROUT SEAL DEPTH <br /> 0 OTHER: GROUT SEAL PUMPED? <br />GROUT SPECIFICATIONS <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 />0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 27** <br />WELL IDs See attached table of well construction <br />GROUT SPECIFICATIONS Neat cement containing <4% bentonite <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />123 OVER-BORE DIAMETER of ** inches to depth of " feet <br />PRESSURE GROUT <br /> <br />To depth of feet below surface <br />EXPLOSIVES <br /> <br />From to feet below surface <br />D MUSHROOM CAP <br /> <br />0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See attached table for well construction details for above information marked with " ** " <br />*** 27 wells include MW-1 thru MW-3, 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- <br />105, SW-102, MW-201 and MW-202. <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Sa 4qaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company VP / Ground Zero Analysis, Inc. Signed I <br />Print Name Gregory Stahl Date ti t 7 (7 <br /> <br />DEPARTMENT USE ONLY <br /> <br />e.-/A 7 <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />S(_1 "reit" <br /> <br />1 <br /> <br />FA Name )76c-fl,ex- .f ) &tic_ FA Address /6 b0 ii -1-1 <br />n 1 v,i2.4,5 FA# <br />tk-C i\a" <br />6007_3 .7 PR# Kari 7407 <br />.7 *i f s/ y 1 1-7 FA PE ‘Z 6 0 WP Reviewed By <br />O'--------- <br />Work Plan Da, ipitA <br />cr(57 0 C-57 Authorization for Other to Sign Perm t Worker s Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 1Lead Agency Approval tE<FR <br />COMMENTS/CONDITIONS: i j AS f l CA-Cia Ci%)...i.k- 0\ L/L,14- 6-d— <br />Ca,_,*51). 4. 1 - ( kJ 2-o? ywcA-4-1 bc.. ce-irj--4 Axp 77: \ Si--6-erIA..04/...eicNC <br />C4-ZZi VVZIC 7 -2J1--tk a <br />ic,...e_v <br />WP TYPE PE SC FEE INFd AMT REMITTED CHECK# REC‘I'D BY DATE WELL PERMIT# INVOICE* <br />Permit <br />Z-' t ot- 3/ $152x x C 760 3370 w— 'iv Woo 3 7 6 e-c <br />186'82Valton Avenue I Stockton,iariorr`q95205Wq9 468M-0-I F 209 464-146 P\;VCsj(eAd om <br />END 29-01 08-01-17 Site Mitigation Well Permit Application