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SA6JOAQLA Environme_ 31 Health Department DESTRUCTION METHOD: (CHECK ALL THAT APPLY) OVER-BORE E1 PRESSURE GROUT El EXPLOSIVES El MUSHROOM CAP DIAMETER of 10 inches to depth of 22 feet To depth of feet below surface From to feet below surface El 3 feet below surface or feet below surface if >3 feet Signed I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaq OrØlnance Codes and Standards, and all other applicable California laws. Title/Company VP / Groun Zer nalysis, Inc. Print NameGregory Stahl Date csik ((/R((7 Date Issued: Application Accepted By: Grout Inspection By/Dates: t I I 1 Destruction Inspection By/Dates: Facility/Site Information COUNTY Greatness grows here. 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 48 Hours Advance Notice Required For All Inspections 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. 140 Ft SE from Corner of HWY 33 & Durham Ferry Road Job Address Intersecton City/State/Zip Tracy, CA Phone 209-942-6018 Cross Street Highway 33 St of Cal Department of Transportation - Paul Property Owner* Cavanaugh APN Cal Trans Right of Way Phone 209-942-6018 Address 1976 E. Dr. Martin Luther King Jr., Blvd C-57 Contractor V&W Drilling Address 1133 Blackhurst Consultant/Sub-Contractor Ground Zero Analysis, Inc. Address 1172 Kansas Avenue City/State/Zip Stockton, CA 95205 License# 720904 City/State/Zip Galt, CA 95632 License# 5023 City/State/Zip Modesto, CA 95351 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER CI MONITORING 0 EXTRACTION (Vapor/Water) 0 SOIL VAPOR PROBE SOIL BORING 0 INJECTION (Air Soaroe, Ozonet 0 OTHER 0 WELL/ SOIL BORING IDs CONSTRUCTION SPECIFICATIONS BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS INSTALLATION TYPE HOLLOW STEM HAMMER/DRIVEN MUD ROTARY PUSH POINT (GP/ CPT) HAND AUGER OTHER: DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED 1 WELL IDs MW-4 GROUT SPECIFICATIONS Neat cement containing <4% bentonite TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE [El PIPE COMMENTS: See attached table for well construction details for some of the above information. DEPARTMENT USE ONLY FA Name '• 7 6 , 13 c._ _cat FA Address 1/ 4,24,i-rti FA# 774 a 70 PR# 1124.1 if VI FA PE 0 WP ,viewed By tj1+- Work Plan Date i y..../, -f .1 . 'Z'-57 0 C-57 Authorization for Other to Sign Permit ItE<Norker's Comp 0 Worker's Comp Waiver Encroachment Permit 0 Access Agreement Er le /ad Ag Approval MFR ''' moth-) +- bt, CzmAr.":1,Nesu.AC 1-7--el) • COMMENTS/CONDITIONS164‘,/ dr y 16.4.4811 6 14,4-iy...S rA,L4te-5 WP TYPE PE SC FEE INFO AMT REMITTED CHECK* RECV'D BY DATE WELL PERMIT* INVOICE* Permit 2401., 315 $152x I 1 /S-7_ 30 7 91 V'-----"' 11/2 i 1868 E. E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application Phone 209-469-7700 Phone 209-522-4119