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Property Owner* Phone 775-240-9201 Lynn Kinder/Sierra Chemical Company Address PO Box 6093 City/State/Zip Oroville, CA, 95966 0 AUGERS 0 HOSE 0 PIPE TREMIE TYPE TO BE USED Signed Print Name 2-Q 3 A K2. EHD 29-01 10-26-2015 222-11 NOV Site Mitigation Well Permit Application /ROAlkw. RECEI V ED ENV NTAL HEALTH FEB 1 3 2018 1868 Hazelton Avenue, Stockton, CA 95205-6232 rERMIT/ SERWCEs 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 Standa,rds. . Job Address 1010 Industrial Drive city/state/zip Stockton. CA. 95206 Phone 209-983-8298 Cross Street S Airport Way APN 177-280-53 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Consultant/Sub-Contractor Tracy Johnston/McGinley and Associates Address 815 Maestro Dr. License* P.E. # C64731 (Exp 6/2019) Phone 775-829-2245 City/State/Zip Reno. NV. 89C1 I CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING 0 HOLLOW STEM BORING DEPTH 30 ft 0 BOLTED TRAFFIC BOX 0 STOVE PIPE EXTRACTION (VaporANatert 0 HAMMER/DRIVEN DIA. OF BOREHOLE 1" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER 4 SOIL BORING S fg PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Da: Casing Depth: INJECTION (As Sorra. • Ozonel 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 Freefail Depth is 30 Ft) WELL/ SOIL BORING IDs 81 through 85 GROUT SPECIFICATIONS DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 0 OVER-BORE DIAMETER of inches to depth of feet 0 PRESSURE GROUT To depth of feet below surface 12 EXPLOSIVES From to feet below surface 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet COMMENTS: Hydropunch technology to be used to collect groundwater samples. Borings to be backfilled with cement slurry the same day. I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San Jo q In ounty Ordinance Codes and Standards, and all other applicable California laws. iw-eZLei 7 Z / .44 / • e FA Name -Ti \•:/L, r ' \-3 vii'arl t • 0_ VI FA Address i Ln 6', :-4.A4*- 1 (:), FASt C.)0 -2-'1'1 'A I FA PE a-4 Si.WP Reviewed By L - )C Work Plan Date -7, I . z., I i cic 0 C-57 EK-57 Authorization tor Other to Sion Permit EWorkers Comp 0 Workers Comp Waiver 0 Encroachment Permit (Access Agreement 0 Lead Agency Approval 91(FR COMMENTS/COpiDMONS: ge4.4 s'iAit • 4,41A t icA 4- .10,2_ 4,s_cjk ctcp:0". 44- -41,t, 150 ..-c, LCI t „;,...21) . -1-,..e.,,,, e, ,,k . _c_ ,,,.._, .. t_ t,„,,,, u ; ,.... , A 4 V - i-i. ,-._ " t: fb SR TYPE PE SC FEE INFO MIT REMITTED CHECK# RECIPD BY DATE SERVICE REQUEST# INVOICE# Permit 2_40 '...0 -5k) $iM -7, &' qs-6 .1-.,u1ki- L - 7\ , IA i oiCe6cijdt) 1 Title/Company Date City/State/Zip Reno, NV, 89511 License* 1012248 Phone 530-589-2019 Address 1725 Davis I.n C-57 Contractor EnProbe, Inc. DESTRUCTION WORK TO BE PERFORMED: *WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS Date Issued DEPARTMENT USE ONLY -31 m1tY (rvo Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site information