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RECEIVED SAN vJ OAQ U I N MAR 18 201SEnvironmental Health Department COUNTY- G r e n f n e s s q ro w s 1 ENVIRONMENTAL HEALTH PERMIT/SERVICES 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 48 Hours Advance Notice Required For All 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 2085 E.Mariposa Road City/State/Zip Stockton,CA Phone 925-988-9800 Cross Street Mariposa Rd.,&8th Street APN 171-290-040 Property Owner* Nancy Sanguinetti Trust Phone 559-709-0942 Address 2928 Dwight Way City/State/Zip Stockton,CA 95204 C-57 Contractor Advanced GeoEnvironmental,Inc. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor Same as above License# Same as above Phone 209-467-1006 Address Same as above City/State/Zip Same as above 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 20 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS na TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 5 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 15 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE El PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes Q No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B-1,B-2,B-3,B-4,B-5 GROUT SPECIFICATIONS PoNand Type II DESTRUCTION WORK TO BE PERFORMED: 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 ElAUGERS E]HOSE [:]PIPE ElMUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: StE wof K >r lA&J JA-It+� 031 -LB/ ZCj%& I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San aquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company PROJECT MANAGER/A.G.E. Print Name TIMOYfiY JVCUELLAR Date (yZ Z010 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: • " Destruction Inspection By/Dates: Facilit /Site Information FA Name Scl r L��r1L�+ i r44 Vtot A Address M�5 ? FA# 00 I,Lv" PR# 0_�,j Z_I FA PE WP Reviewed By Work Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit [gWorker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit []Access Agreement []Lead Agency Approval 01GFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED1 CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit }'j;,'> j1;g $152 x -5 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 site Mitigation Well Permit Application