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SAN JOAQUIN s COUNTY-- Greatness grows here. 11( Environmental W#Hirc.,;it 1 26 Osi SITE MITIGATION WELL & BORING PERMIT APP ON-1EALTH For Wells and Borings Used for Contaminant Investigations and RemAgifictiS 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 Job Address 1245 W. Charter Way S Fresno Street Cross Street APN 163-230-080 Phone 209-848-3272 Stockton, CA 95206 City/State/Zip Property Owner* Geo Properties, Inc., George Betker Phone 209-848-3272 2306 Jackie Court Oakdale, CA 95361 Address City/State/Zip C-57 Contractor V&W Drilling, Inc. License# 720904 209-469-7700 Phone City/State/Zip Galt, CA 95632 Consultant/Sub-Contractor Ground Zero Analysis, Inc. License# PG 5023 Phone 209-522-4119 Address 1133 Blackhurst Drive Modesto, CA 95351 City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 0 HOLLOW STEM BORING DEPTH 0 BOLTED TRAFFIC BOX 0 STOVE PIPE EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE El MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes Cl No Boring Dia: Casing Dia: Casing Depth INJECTION (Air Saarge, Ozoriel 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freetall Depth is 30 Ft) WELL/ SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY1. # WELLS TO BE DESTROYED 22 in OVER-BORE DIAMETER of * inches to depth of * feet WELL IDs See attached Table IA PRESSURE GROUT To depth of * feet below surface Address 1172 Kansas Avenue GROUT SPECIFICATIONS See Tables and Work Plan TREMIE TYPE TO BE USED 5 AUGERS 0 HOSE a PIPE EXPLOSIVES From to feet below surface a MUSHROOM CAP [33 feet below surface or feet below surface if >3 feet COMMENTS: * Refer to the Well Destruction Method Spreadsheet, Grout Calculations and Well Destruction Work Plan for well specific information. I hereby certify thatI a authorized to complete this application and that the work will be done in accordance with 7 f Joaqu (Coun odes and Standards, and all other applicable California laws. Title/Company PG / Ground Zero Analysis, Inc. Signed Print Name Gregory Stahl Date 5- 5 1-- d,o)R DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates Facility/Site Information Date Issued: I FA Name ific". v '-11NiN iv-cr-1.14411-- AN.,e4,6-1 _c_i) FA Address ' .."- ‘1"1 . Gi'sINA-V-V- " . FA# r 0 OD—I 2-y PR# (-( 2_ , FA PE , --)-1, t•-: WP Reviewed By I---)e Work Plan Date 0 C-57 0 G-57 Authorization for Other to Sign Permit 111 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit einet Agreement 0 Lead Agency Approval 0 MFR COMMENTS/CONDITIONS: , v , , ‘, , „e.:„..,e, e WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# Permit $152x 1 V -71/ 17...W ''''''CCIO /A4 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com„ iic END 29-01 08-01-17 Site Mitigation Well Permit Application ,.>(O C. P 5 4ç 2-)t 3 t"53' 3 (1..-C ) 1'6 I ". t—X