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SA N d OAQ U I N Environmental Health Department. ----COUNTY SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice required For All Inspections CAl 1. (209) 953-7597 For 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 Stockton Metropolitan Airport,5000 S Airport Way CitylState/Zip Stockton,California 95206 Phone (209)468-4700 Cross Street Arch Airport Road APN 177-260-470 Property Owner* County of San Joaquin Phone (209)468-4700 Address 5000 S Airport Way City/State/Zip Stockton,California 95206 C-57 Contractor M R Drilling License# C-57#740854 exp.,9/30/25 Phone (714)994-0402 Address 7431 Walnut Ave City/State/Zip Buena Park,California 90620 Consultant/Sub-Contractor BSK Associates License# n/a Phone (559)497-2880 Address 9332 Tech Center Drive,Suite 100 City/State/Zip Sacramento,California 95826 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH apnrox-coft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS n/a TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER 91 SOIL BORING �_❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: n/a Casing Dia:_p ja Casing Depth: n/a ❑ INJECTION(Air Soarae.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs B-35 L: GROUT SPECIFICATIONS Neat cement with 5%bentonite. See attached workplan. DESTRUCTION WORK TO BE PERFORMED: N/A DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin my Ordinance Codes and Standards,and all other applicable California laws. Signed—�� .. Title/Company £ 1tJ��Pl�t-C- LGIST Print Name &9-e d- "Tbn�./ f 4T`�-i1�1 Date 3� ZOw DEPARTMENT USE ONLY Application Accepted By: Date Issued: 7 Grout Inspection By/Dates: Destruction Inspection By/Dates: Fa ill /Site Information FA Name Address 5 FA# pp) -4 14 PR# FA PE WP Reviewed By Work Plan Date f ❑'b457 fa.C•57 Authorization for Other to Sign Permit Worker s Comp ❑Workers omp Waiver ❑Encroachment Permit ❑Access Agreement $[Lead Agency Approval 7C)MFR (COMMENTS/CONDITIONS: 627 17✓LL p;4��—i WP TYPE PE Sc FEE INFO AMT REMITTE CHECK# RECV'p BY DATE WELL PERMIT# INVOICE# Permit /0' 311 $172 x �3 1 HIV 15 O� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-32420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 09-01.2024 tea,Z,� Site Mitigation Well Permit Application