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Pa�I t. p SAN JOAQUIN COUNTY <br />a• -fit' .o <br />—` yz ENVIRONMENTAL HEALTH DEPARTMENT <br />N K <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />�q•. c .• Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.socehd.com <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 825 Navy Drive <br />Cross Street Argonaut Street <br />City/State/Zip STOCKTON CA 95206 <br />APN 163-260-35 <br />Phone 209 944-0909 <br />Property Owner` Phillips, John B & Bonnie Phone <br />Address 1133 Bristol Avenue City/State/Zip Stockton, CA 95204 <br />C-57 Contractor ADVANCED GEOENVIRONMENTAL, INC. License# 680227 Phone <br />Address 837 SHAW ROAD <br />City/State/Zip STOCKTON CA 95215 <br />209 944-0909 <br />209-467-1006 <br />Consultant'Sub-Contractor A.G.E. License# 680227 Phone 209-467-1006 <br />Address 837 SHAW ROAD City/StateOp STOCKTON CA 95215 <br />`Note: Offsite Borings=ells Require Access Agreements or Encroachment Permits <br />TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORINGDEPTH 5-10' ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE NA <br />❑ EXTRACTION (VW/ Waer) ❑ HAMMER/DRIVEN DIA OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER NA <br />IN SOILBORING 5 (9 PUSH POINT (GPI CFO CONDUCTORCASING C1 Yes 0 N Boring Da: 2° Casing Dia: NA CalgDepth: NA <br />❑ INJECTION (Air soarae. omnel ❑ HAND AUGER GROUTSEALDEPTH 10' TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE $I PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes (M No (Note: Murrurn Freefell Depth is 33 Ft) <br />WEW SOIL BORING IDs GP3 through GP7 GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUTS <br />TREMIE T <br />Signed <br />Print N <br />SEE WORK PLAN DATED 16 OCTOBER 2015 <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />❑ OVER -BORE DIAMETER of _ inches to depth of feel <br />❑ PRESSURE GROUP To depth of feet below surface <br />❑EXPLOSIVES From to feet below surface <br />artily that I am authorized to complete this application and that the work will be done In accord <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company PROJECT GEOLOGIST/AGE <br />Date 13 January 2016 <br />—/I DEPARTMENT USE ONLY <br />Application Accepted By://��f/GKUH/T�fi' Date Issued: <br />Grout Inspection By/Dates: /l%iiLi/ Wi'-GcOYP/,fos'] //Z2 /L <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name <br />FA Address <br />FA# <br />PRO <br />FA PE <br />WP Reviewed By <br />Work Pian Date <br />❑ C57 ❑ C-57 Authonnfion fu Olherto Sign Permit ❑ Workers Comp ❑ Workers Comp Waiver ❑ Encmachment Permit ❑ Access Agreement ❑ Lear Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE <br />PE <br />Sc <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />SERVICE REQUEST# <br />INVOICE# <br />Work Plan <br />29tH <br />5zj <br />396 <br />390 <br />07f <br />6A17C <br />J /G <br />5R007g04 <br />Permit <br />220—f <br />313 <br />$130x -5= <br />4.390 <br />6v7P` <br />///;-/W <br />31ZO0741Oq- <br />EHD 29-016-23-2015 <br />Ap"�ee 2/3//G <br />Site Mitigation Well Permit Application <br />