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RECEIVED <br /> FEB 17 2016 SAN JOAQUIN COUNTY DEC 0 3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT 2415 <br /> B�eelton Avenue, Stockton, CA 95205-6232 CNViRONMCNTAi_11EAl,.TI•i <br /> 1­19;= t_3420 Fax:(209)468-3433 Web:www.sicehd.com PERMIT/SERVICES <br /> `S <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 fora 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 /> Cit <br /> tandards. <br /> City Of Tracy Right-of-Way on north side parking lane <br /> Job Address of W. Beverly Place and south side sidewalk. citylstate2lp Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN NA <br /> Property Owner' City of Tracy Phone 209-831-6400 <br /> Address 333 Civic Center Plaza 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 cftylstatelZip Sacramento, CA 95826 <br /> Consultantsub-Contractor Advanced GeoEnylronmental, 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 BonngsWells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOVLON STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VaprNJater) ❑ HAMMEWDRIVEN CA OF BOREHOLE ❑WULTIPLE CASINGS O MULTI{EVEL WELL.CASING DIA <br /> ❑ SCILVAPORPROBE ❑ MUD ROTARY CASING TH"NESS TYPE OF CASING: ❑STEEL❑PVC❑ OTHER <br /> ❑ SOLBORING ❑ PUSH POINT(GPI CPT) CMDUCTORCASING ❑Vas 0N Boring ax Caft Da: Casing Depth: <br /> Cl INJECTION MSesae oma) ❑ HANDAUGER GROUT SEAL DEPTH TREMETYPETOBEUSED: ❑AUGERS❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [3 Yes 0N QW.WladrrmFrwWlDWhN3DFli <br /> WELUMLBORNG10e GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHATAPPLY) <br /> #WELLS TO BE DESTROYED 2 monitoring wells 2t1 OVER-BORE DIAMETERof. 8 Inchesiodepthof 25 feet <br /> WELL Los MW-3 and MW-4 ❑PRESSURE.GROUT To depth of_feetbelow surface <br /> GROUT SPECIFICATIONS Portland Type II (941b+ 5:.5-6 gallons) ❑EXPLOSIVES From_to_feel below surface <br /> TREMIETYPE feet below surface If>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 <br /> I hereby certify that Iam authorized to complete this application and that the work will be done in accordance with <br /> an'Joaquin County Ordinance Codes and Standards,and all other applicable California laws <br /> Signed Title/Company PROJECT GEOLOGIST/AGE <br /> Print Name BRIAN MILLMAN Date 12/02/2015 <br /> �v ! ��� � 0�� <br /> Application Accepted By: DEPARTMENT USE ONLY Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faciti y/Site Information <br /> FANanre FAA IFA# I IPW <br /> FA PE WP Reviewed By 1workpwoate <br /> ❑CST ❑Cbl Au zolonfa00erb.Sgn Penia ❑WMkees.CmV ❑Worker's ComP Waver ❑emadment PemN ❑Aaesa Agieerent ❑LeW Agm Appal C)MFR <br /> COMMENTSICONDITIONS: <br /> Ly yQy,�x.A � �y-iyyQl y�rx p7. ak; VrWVAs.1 lira <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RESVD BY DATE SF_Ry10EREQUES7Yi INVOICE# <br /> Work Plan <br /> Pemift 2911 13 $130x <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />