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SAN JOAQUIN <br />-COUNTY <br />Environmental Health Depatrimelit <br />Greatness grows here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Welts 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 Inspectiomi <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 />LIcense# 720904 Phone 209-469-7700 <br />LIcense# 5023 Phone 209-522-4119 <br />Job Address 1680W Durham Ferry Road <br />Cross Street Highway 33 <br />TeranIshl Irrevocable Administrative Trust, Sheldon <br />Property Owner' TeranIshl <br />City/State/Zip Tracy, CA 95304 Phone 209-522-4119 <br />APN 255-100-39 <br />Phone 209-522-4119 <br />City/State/Zip Bodega Bay, CA 94923 Address PO Box 315 <br />C-57 Contractor V&W Drilling <br />Address 1133 Blackhurst <br />Consultant/Sub-Contractor Ground Zero Analysis, Inc. <br />Address 1172 Kansas Avenue <br />City/State/Zip Gall, CA 95632 <br />City/Slate/Zip Modesto, CA 95351 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Of fsite Borings/Wells Require Access Agreements or Encroachment Permits <br />WELL IDs See attached table of well construction <br />GROUT SPECIFICATIONS Neat cement containing <4% bentonite <br />TREMIE TYPE TO BE USED CI AUGERS EJ HOSE El PIPE <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 />Title/Compan VP / Ground Zero Analy sts, Inc. <br />Date ( ( 7 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />DEPARTMENT USE ONLY <br /> Date Issued: if/1/h <br />FM MOOS-3 70 FA Address 1/6 210 hI ift-C k...1-1hT4I-4111 <br />Signed y <br />Print Name Gregory Stahl <br />Work Plan Dais F /, .7 I..) yi /.7 <br />0 Access Agreement 0/Lead Ag ncy Approval efolFR <br />,v be__ Le ‘,4 444 fel.C4 1 -2-.? <br />7r,-ex 6 Lc ar <br />2,9 FA PE <br />Destruction Inspection By/Dates: <br />FacilitylSae Information <br />FA Name <br />WP Rpilewed By <br />El C-57 0 C-57 Aulhormattal for Other to Sign Permit El/Worker'e Comp <br />fkari,zfett <br />t y r‘l zo rA" be- n.,4-41 AA. <br />I hereby certify that I a authorized to complete this application and that the work will be done In accordance with <br />Sa .,1çflqul rdlnance Codes and Standards, and all other applicable California laws. <br />COMMENTS/CONDITIONS: ,( <br />0 Worker's Comp Waiver 0 Encroachment Permit <br />WP TYPE PE SC FEE INFd AMT REMITTED CHECK0 RECV'D BY DATE WELL PERMIT# INVOICE# <br />pe rmit -7L'i oz„ 313 $152x ,Sr--- r 7 60 30 .7 60 p.-- I il z,/ iii) 00 37‘ e.-0 <br />2-gRa t 1868 . elton Avenue Stockton, anfornia 95205T71g9 468r.----3420 F 209 464-W1313 p ow sicAd am <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br /> 0 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 />0 MULTIPLE CASINGS 0 MULTILEVEL WELL CASING DIA <br />TYPE OF CASING. 0 STEEL IO 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 Freelall Depth is 30 FI) <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (VapodWatei) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION iikji Some. Ozonel <br />ID OTHER <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> o PUSH POINT (GP/ CPT) <br /> ij HAND AUGER <br />o OTHER: <br />VVELU SOIL BORING IDs <br />DESTRUCTION WORK TO BE PERFORMED: <br />WELLS TO BE DESTROYED 27" <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />Z OVER-BORE DIAMETER of " inches to depth of " feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From lo feet below surface <br />MUSHROOM CAP 0 3 feet below surface or feel below surface if >3 feet