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City/State/Zip Huntington Beach, CA 92649 if/V/4 leii7/1t Date Issued: /eA7//8 Application Accepted By: Grout Inspection By/Dates: DEPARTMENT USE ONLY lva4( efriok/5e- EHD 29-01 10-26-2015 29C 5I CO 7‘ if Site Mitigation Well Permit Application .271/7 2/1 7 09 ,161C-- It- aAdY eAAI -1-wr e ft() .60 AA, SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com 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 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. City/State/Zip Stockton, California 95202 Phone Cross Street E Oak Street and N EL Dorado Street APN 139-060-32 Property Owner TARVINDER K. BAINS, TRUSTEE OF THE TARVINDER K. BAINS REVOCABLE LIVING TRUST DATED OCT*WW2, 2007 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits Job Address 520 North El Dorado Street 9498008341 Address 6111 'Furnberry CL City/State/Zip Dublin, CA 94568 License# #695970 Phone 916 417 6858 Address 4952 Warner Ave, Suite 242 NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 HOLLOW STEM BORING DEPTH 15 ft bgs 0 HAMMERAAVEN DIA. OF BOREHOLE 2.5-inch 5 0 MUD ROTARY CASING THICKNESS 1/4-inch 120 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes III No ID HAND AUGER GROUT SEAL DEPTH 0 OTHER: GROUT SEAL PUMPED? 0 Yes 0 No 0 BOLTED TRAFFIC BOX 0 STOVE PIPE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA TYPE OF CASING: 0 STEEL VI PVC 0 OTHER Boring Dia: 2.5-inch Casing Dia: 1/4-inch Casing Depth: 1511 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE n PIPE (Note: Maximum Freefall Depth Is 30 Ft) TYPE OF WELL/BORING MONITORING EXTRACTION (Vapor/Water) EI SOIL VAPOR PROBE SOIL BORING INJECTION (Air Soarge. Om* OTHER WELU SOIL BORING iDs SV-1 through SV-5 DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL Ds GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE COMMENTS: 1/4-inch soil vapor probes installed at 5 ft and 15 ft bgs in direct push borings. DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 0 OVER-BORE DIAMETER of inches to depth of feet 0 PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface 0 MUSHROOM CAP p 3 feet beiaior surface or feet below surface if >3 feet .... I hereby certify that I am authorized to cogj7te this application and that the work will be done In accordance with San Jo u Co ' Ordinan• :,- odes and Standards, and all other applicable California laws. Li. Title/Company Frontier Real Estate Investments, Inc • Signed Print Name - • Date September 26, 2016 Destruction Inspection By/Dates: Facility/site FA Name intormation FA Address FM PR# ..- FA PE WP Reviewed By i .//:/v.,/ .i le, /,,,-yoki Work Plan Date 3a /6 ....- , dC'-157 0 C-57 Authorization for Other to Sign Permit 194Orker's Comp 0 Worker's Comp Waiver 0 Encroachment Pertnit LiKc'cess Agreement 0 Lead Agency A Ili MFR COMMENTS/CONDITIONS:,A.,,?4,,,4 i--,,,A. I, c 5-44943 i..,..)etts Plust-beele-ote tiktdiv- ..9-eliaea le "ev-04, i--- 44.,.,)n-weitia-e l' we a e44,444.17 u,,i( he rervtr - SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit 2-)c, i 313 $139x 5 6)5 `)Y5141'&" SA co 740 z 5 GROUT SPECIFICATIONS g.e C-57 Contractor Environmental Control Associates, Inc. Address 3011 Twin Palms Drive Consultant/Sub-Contractor Terrax Environmental, Inc City/State/Zip License# 972760 Phone 714 717 1037 Aptos, CA 95003