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REGtiVtu RECEIV ED FEB 17 2016 SAN JOAQUIN COUNTY DEC 02015 ENVIRONMEFOMYCIRONMENTAL HEALTH DEPARTMENT HEALTH DEPARITMFB IWazelton Avenue, Stockton, CA 95205-6232 FNVII!0NMENTAyLHFALTl9 Telephone:(209) 468-3420 Fax.(209)468-3433 Web:www.sicehd.com 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 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 101 West Beverly Place City/StateRip Tracy,CA 95376 Phone 800-511-9300 cross street Holly Drive APN 233-152-26 Property Owner" Vicki L. Myers Phone Address 101 West Beverly Place City/State/Zip Tracy, CA 95376 C-67 contractor All Well Abandonment, Inc. License# 848359 Phone 916-363-9355 Address 9245 Beatty Drive Suite A city/StateOp Sacramento, CA 95826 Consultant/Sub-Contractor Advanced GeoEnyironmental, Inc. License# 680227 Phom 800-511-9300 Address 837 North Shaw Road city/statemp Stockton CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TIDE OFWEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLONSTEM BORING DEPTH ❑BOLTEDTRAFRGBDX ❑STOVE PIPE ❑ EXTRACTION(VaraMater) ❑ WMMffMVEN CIA OF BOREHOLE ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DW ❑ SOILVAPOR PROBE ❑ NIUD ROTARf CASING THICKNESS TYPE OF CASING:❑STEEL O PJC❑ OTHER ❑ SOIL BORING ❑ PIMPOINT(GP/CPT) CONDUCTOR CASING ❑Yes ONO Bering Dia: Caft GIs. Casing Depth: ❑ INJECTION(alrsmrae.0the ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETORE USER ❑AIDERS CHOSE❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUhpE6t ❑Yes ❑No. (tole:Maximum FreeM Depth is 30 Fq WELU ROIL BORING IDs GROUTSPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLSTOBEDESTROYED 1 dual-completed monitoring well 91OVER-BOREDIAMETER of 12 inches to depth of 24 feet WELL Ins MW-6 ❑PRESSUREGROUT Todepthof feetbelmsudace GROUT SPECIFICATIONS Portland Type II (941b + 5.5-6 gallons) ❑EXPLOSIVES From_to_feet below surface TREMIETYPETO BE USED AUGERS ❑HOSE ❑PIPE F]MUSHROOM CAP ❑3 feet beim surface or last below surface 1>3 fest COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 I herebycertify that 1 am authorized to complete this application and that the work wiH be done inaccordance with Q San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed 1/= / � :-- Title/Campany PROJECT GEOLOGIST/AGE Print Name BRIAN MILLMAN Date 12/02/2015 DEPARTMENT USE ONLY Application Accepted By: 0/'/ Date Issued: Grout Inspection By/Dates: / S iGA,,wil ✓i o Destruction Inspection By/Dates: Facili /Site Information FANartre I FA PE WPewd FA# Work Plan DatePR# ❑C67 ❑CS7Aadiwrization larOlherlo Sign Permit ❑VVmWsCemp ❑Workers Comp Warn ❑Enaoeehment Permit OAceessAgrearent ❑UndAgNwy Approval ❑MFR COMMENTS/CONDITIONS: b�Crdr:t(ed W/ 1-ttw4.a. r,-r `rfe+ Ztr kvji dwsvhr,� aft !r f '/JY� fi jj yr/ r.F.,tr SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit $130x EHD 29-016-23-2015 Site Mitigation Well Permit Application