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oF4�.!IY, o <br /> SAN JOAQUIN COUNTY 41 RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 03 2015 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> :P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s•cehd.4RONMENTALHEALTH <br /> ERMIT/SERVICES <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 104 West Beverly Place City/state/Zip Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN 233-153-13 <br /> Property Owner* Juan Manuel Baeza Phone <br /> Address 104 West Beverly Place city/state/zip Tracy, CA 95376 <br /> C-57 Contractor All Well Abandonment, Inc. License# 848359 Phone 916-363-9355 <br /> Address 9245 Beatty Drive Suite A City/State/zip Sacramento, CA 95826 <br /> Consultant/Sub-contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road City/state/zip Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes CI No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(A,Searae.Ozmel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefel Depth is 30 Ft) <br /> WELL!SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 3 monitoring and 5 vapor Wells EI OVER-BORE DIAMETER of to 8 inches to depth of5 to 25feet <br /> WELL IDs MW-1 MW-2, MW-8 and V-1 through V-5 ❑PRESSUREGROUT Todepthof feet below surface <br /> GROUT SPECIFICATIONS Portland Type II (941b + 5.5-6 gallons) ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE -1 MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �/L'-' Title/Company PROJECT GEOLOGIST/AGE <br /> Print Name BRIAN MILLMAN Date 12/02/2015 <br /> l,, DEPARTMENT USE ONLY <br /> Application Accepted By: /Y//,(� 'SGL` ' Date Issued: //'y/1r/C <br /> Grout Inspection By/Dates: ���� ) ,� <br /> Destruction Inspection By/Dates: •NI�G�� CS r1 z/2—P <br /> Facility/Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Workees Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMM ENTS/CONDITIONS: <br /> SR TYPE PE I SC I FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2943 152,3 1 3'90 1 f 3971 1/253-6 I CIV71? 1 /z/3/S 5 f2 06715 �6<1 <br /> Permit 21902 31_5 $130 X S �CJ�� ZS�6 Piv7"fQ 7111 /f- I ,S A 6 V'73%5' <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />