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� �iat 'a..® SAN JOAQUIN COUNTY RECEIVED oma. N X016 ENVIRONMENTAL HEALTH DEPARTMENT DEC 03 2()15 E 1868 Hazelton Avenue, Stockton, CA 95205-6232 a.. • H i B)re (209)468-3420 Fax: (209) 468-3433 Web:www 5 cehd. 60NM[NTAL HEALThI HEAL � �GATION WELL &BORING PERMIT APPLICATIONT/sEwlcEs 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 104 West Beverly Place City/stateop Tracy, CA 95376 Phone 800-511-9300 Cross street Holly Drive APN 233-153-13 Property Owner* Juan Manuel Baeza Phone Address 104 West Beverly Place city/State/zip Tracy, CA 95376 C-57 Contractor All Well Abandonment, Inc. License# 848359 Phone 916-363-9355 Address 9245 Beatty Drive Suite A City/State/zip Sacramento, CA 95826 Consultant/Sub-contractor Advanced GeoEnvironmental,Inc. License# 680227 Phone 800-511-9300 Address 837 North Shaw Road City/state/zip Stockton CA 95215 CONSTRUCTION.WORK TO BE PERFORMED:*Note.- Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapv/Water) ❑ HAMMERIORNEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL EI PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/GPT) CONDUCTOR CASING O Yes ❑No Boring WB: Casing Dia: Casing Depth: ❑ INJECTION(AlrSome.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO 13E USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yea EI No (Note:Maximum Freefell Depth is 30 FQ WELLI SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 monitoring.and 5 vapor Wells Z]OVER-BORE DIAMETERof3 to 8inches bdepth of5 to 25feet WELL IDs MW-1, MW-2, MW-8 and V-1 through V-5 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland Type II 9411D + 5.5-6gallons) ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED MAUGERS []HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feetbBlow surface or feet below surface If>3 feet COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /t - Title/Company PROJECT GEOLOGIST/AGE Print Name BRIAN MILLMAN Date 12/02/2015 /1/� DEPARTMENT USE ONLY Application Accepted By: /Yf/,C�� Date Issued: Grout Inspection By/Dates: Destruction inspection By/Dates: r f Y 2 /te Facillt /Si a Information FA Name FA Address FA# PR# FA PE I Work Plan Date ❑C-57 ❑C-57 Aulhwkatkm for Othefto Sign Pennll ❑Workees comp ❑Worker's Comp Watw ❑Encroachment Permt. ❑Access Agreement. ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICEREQUEST# INVOICE# Work Pian 2�Q3 152,3 39t? /2556 CtLIre /Z /S S'20615 9G�`q Permit 2942 3/j $130x ,S �„je ZSd'(o C✓U7fQ z,1J 1f YA0V`739G5 ❑un oo n� a w oma co.,edaa,...n...,mr.,n o., :. A....r....,,:.,..