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AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue Stockton CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wwwsicehd.com Sffl E MITIGATION WELL & BORING PERMIT APPLICATION Foil, WeH , 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. Job Address Stockton Metropolitan Airport, 5000 S Airport Way City/State/Zip Stockton, California 95206 Phone (209) 468-4700 Cross Street Arch Airport Road APN 177-260-340 Property Owner's _Coup y 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 13124 Firestone Blvd. City/State/Zip Santa Fe Springs, CA 90670 Cons ultant/Sub-Contractor BSK Associates License# n/a Phone (559) 497-2880 Address 3140 Gold Camp Drive #160 City/State/Zip Rancho Cordova, California 95670 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUGTION SPECIFICATIONS ® MONITORING ^3 ❑ HOLLOW STEM BORING DEPTH approx. 60ft ®BOLTED TRAFFIC BOX CJ STOVE PIPE ❑ EXTRACTION(Vapor/Water) ElHAMMERIDRIVEN DIA.OF BOREHOLE g" ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ©No Boring Dia: $" Casing Dia: 2" Casing Depth: 60ft ElINJECTION(AirSoaroe.Ozone t ElHAND AUGER GROUT SEAL DEPTH Depth of boring TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs M\A/-1 MW-2 anti MVU-4 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 au, orized to complete this application and that the work will be done in accordance with an Joaqui inar= Codes and Standards, and all other applicable California laws. Signed Title/Company Pr�'rK.� ' i Print Name o P.� \\TynV / rYyetrOF712 Date i o • DEPARTMENT USE ONLY Application Accepted By: Dale Issue;I: tiL['&,e, Z�f Grout Inspection By/Dates: 14Z Destruction Inspection By/Dates: Facilit /Site Information FA Name k -;,,,X ! i� , FA Address �- , ,- FA# PR# �- FA PE t-.1 J t, WP Reviewed By Work Plan Date ❑C-57 EJ C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement �Lead Agency Approval Cl MFR COMMENTSICONDITIONS: _ � -�sew(1��. ��, � �rl s•��.� � ��,� �.��•� 1Lti Lc'- SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit f1f l4 331 4- s3 ��- a�•�3 w�mm45mg� EHD 29-01 6-23-2015 Site Mitigation Well Permit Application