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RECEIVE® SANJOAQUIN MAR 28 201gEnvironmental Health Department --C O U N T YENVIRONMENTAL HEALTH I,,,, ,,:," Greotness grows here. 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 2828 Dwight Way CitylState/Zip Stockton, CA 95204 C-57 Contractor Advanced GeoEnvironmental, Inc. License# 880227 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 BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 2O feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Watar) L1 HAMMERIDRIVEN DIA.OF BOREHOLE 24nch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS na TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER Ed SOIL BORING 5 ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dla: Casing Depth: ❑ INJECTION08oerae.Omne1 ❑ HANDAUGER GROUT SEAL DEPTH 15 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ©No (Note:Maximum Freelall Depth is 30 Ft) WELL/SOIL BORING IDS B-1,B-2,B-3,B-4,B-5 GROUT SPECIFICATIONS Portland 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 feel WELL IDs ❑PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel COMMENTS: SYP wofVC ?AN JgTtp o$I qt/ Zotitt I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San(yaqum u County Ordinance Codes and Standards, and all other applicable California laws. Signed R. Title/Company PROJECT MANAGERIA.G.E. Print Name TIMOYflY JOCUELLAR Date 4ft9la (W Z8 1 ztoy DEPARTMENT USE ONLY (� Application Accepted By: Dale Issued: y I 1 ( r9 Grout Inspection By/Dates: 3 Destruction Inspection By/Dates: Facilit /Site Information '',,tL, 1 I 1 FA Name Scty-c o,L ne + l f-,A � Q ,t AAddress )��y 6, t`hWv1 fJ� Q.LI FA# Q(� 7-��`'' PR# r FA PE WP Reviewed By Work Plan Date ❑C-57 C-57 Authorization for Other to Sign Permit M"Workers Comp ❑Workers Comp WaNer ❑Encroachment Permll ❑Access Agreement ❑Lead Agency Approval 1F 4FR COMMENTS/CONDITIONS: WP TYPE I PE SC I FEE INFO JAMT REMrr-rEDj CHEK�C K# RECV-D BY DATE WELL PERMIT# INVOICE# Permit ,�-"IO i 513 $152 X 3 � '6J�a 7,> oo I L, i;� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD29-01 09-01-17 _ I Site Mitigation Well Permit Application 114 :not SZ3 4 iS" 3 4%-1 Z`l s`E� I- -X #A I t V1 - CA 0"19z4 YZ