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o "• ` AN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMENT •: 868 Hazelton Avenue Stockton CA 95205-6232 Telephone: (208) 468-3420 Fax: (209) 468-3433 Web: www.sacehd.com WE ICI L IG KU—H WME-LL & ORS NG PERMIT APPLICATION E cm, Wells and Borings Used for Contarnilnant 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 177-260-470 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#f 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 BSI<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 WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH _ loft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) © HAMMER/DRIVEN DIA.OF BOREHOLE 2" push probe❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS n/a TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 4 _❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: _ n ja Casing Dia: n/a Casing Depth: n/a ❑ INJECTION(AirSparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH Depth of boring TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE'Ej PIPE n/a depth less than 30 ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes El No (Note:Maximum Freefall Depth is 30 Ft) WELL/ BORING IDs H-?7 through B-3n- GROUT SPECIFICATIONS Neatcementwith5%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 JoaclyffiVounty Ordinance Codes and Standards,and all other applicable California laws. Ilk Signed Title/Company�('•j ref L 6ef) 1,124" � j �e— A&<ZC Print Name �Qber-IL ,L j a%. &1ZT— 1n Date I h DEPARTMENT USE ONLY Application Accepted By:_ A Date Issued: 1 I� �,�✓( Grout Inspection By/Dates: Destruction Inspection By/Dates: 61� 20 Zw -- Facility/Site Information t FA Name �'ifL(,.-,ter FA Address I FA# Is'° '� 1" �; PR# I FA PE -, , { WP Reviewed By I Work Plan Date r ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit X a l�- t 3 3��-8 3 ►�• �2•a3 wPm�45m $� END 29-01 6-23-2015 Site Mitigation Well Permit Application