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R EIVED <br /> gqulry• c 'r E3 17 2016 SAN JOAQUIN COUNTY DEC 03 2015 <br /> R ENVIRONMENTAL HEALTH DEPARTMENT <br /> ° I :14VIRONMENT aaelton Avenue, Stockton, CA 95205-6232 �Npft�SNTA( yFRCTFt <br /> ° i- 468-3420 Fax:(209)468-3433 Web:www.sicehd.com �fGES <br /> "6a <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> j 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 42 West Beverly Place Cityistateop Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN 233-153-14 <br /> Property Owner` Juan and Marla Ibarra. Phone <br /> Address 42 West.Beverly Place City/Stateop Tracy, CA 95376 <br /> C57 contractor All Well Abandonment,Inc. License# 848359 Phone 916-363-9355 <br /> Address 9245 Beatty Drive Suite A City/State0p Sacramento, CA 95826 <br /> Consultant(Sub-Contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road City/Statelzip Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OfTsite BoringsM/elis Require Access Agreements or Encroachment Permits <br /> TYPE OFWEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM HORNGDEPIH ❑BOLTED TRAFFIGBOX ❑STOVEPIPE <br /> ❑ DaRACTION(VapaMJder) ❑ HAMMERRBUVEN DIA CF.BOREHOIE ❑MULTIPLE CASINGS O MULTI-LEVELWELLCASING CIA <br /> ❑ SOLVAPORPROBE ❑ MUD ROTARY CASING THICKNESS. TYPE OF CASING: 0STEEL❑PVC❑ OTHER <br /> ❑SOILBORING ❑ PUSH POINT(GP/CPT) CQJWCTORCASING ❑Yes 0N Bait da: Ging Da: Caft Depth:. <br /> ❑ INJECTION(Aksom .Dmnel ❑ HAND AUGER GROUT SEAL DEPTH TREMETYPETOBEUSED: ❑AUGERS❑HOSE❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED7 ❑Yes 13 No (Nola:MLairum Freefd Depth is 30 Ti) <br /> N'EW SOIL BORING IDs GROUTSPECFICAT(ONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:TCHECKALLTHATAPPLI1 <br /> #WELLS TO BE DESTROYED 1 monitoring well ❑fit-BORE DIAMETER of_Inches to depth ofu feet <br /> WELL IDs MW-7 MPRESSUREGRcur Todepthof 14 feet below surface <br /> GROUT SPECIFICATIONS Portland Type II (941b + 5.5-6 gallons) [I EXPLOSIVES From_to—feetbelow.surface <br /> TREMIE TYPE TO BE USED ❑AUGERS HOSEPIPE KI MUSHROOM CAP W 3feet ban surface or feet below surface B>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 <br /> 1 hereby certify that]am authorized to complete this application and that the work will he done in:accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company PROJECT GEOLOGIST/AGE _ <br /> Print Name BRIAN MILL AN Date 12/02/2015 <br /> �^ /�` //�� �� __// DEPARTMENT USE ONLY <br /> Application Accepted By: /1 ""/ f7•�ECfe G%l Date issued: f/�1 <br /> Grout Inspection BylDates: /�� <br /> Destruction Inspection By/Dates:0 1„/!� xC�`tr", <br /> Rili (Site Information <br /> Name FA Address ———TF—A#—T I PF& <br /> FA PE I I Wak Ran Date <br /> ❑C57 ❑WMhazafiMWOlarb Sign Pemrl ❑WorWsODV ❑Wakerscanpwaiver 01imsOhnerflPsrae OAooeseABreement ❑LeadAWMAppraal ❑MFR <br /> COMMENTSICO NDITIONS: <br /> SRWPE PE SC ME INFO AMT REMITTED CHECK# RECZM <br /> SERVICE REQUEST# INVOICE# <br /> Work Plan q <br /> Permit 2g 2 313. 130x ( 13U IZS&'lD �. S& jJ <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />