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• • RECEIVED <br /> ip <br /> SAN JOAQUIN COUNTY DEC 0 3 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sacehd.com PERMIT/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 /> City Of Tracy Right-of-Way on north side parking lane <br /> Job Address of W. Beverly Place and south side sidewalk. City/Staterzip 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 CityBtate/Zip Tracy, CA 95376 <br /> C-67 Contractor All Well Abandonment, Inc. License# 848359 Phone 916-363-9355 <br /> Address 9245 Beatty Drive Suite A City/StaterZip Sacramento, CA 95826 <br /> Consultant/Sub-contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road City/states ip Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offs@e BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORINGDEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXFRACTION(VaportWatu) ❑ HAMNERIDRVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PJC❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Ua: Casing Dia Casing Depth: <br /> ❑ INJECTION(NrSmae Omne) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED. El AUGERS ❑HOSE C]PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Madr kn Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 monitoring wells JKI OVER-BORE DIAMETERof 8 inchestodepthof 25 feet <br /> WELL IDs MW-3 and MW-4 ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS Portland Type II (941b + 5.5-6 gallons_❑EXPLOSIVES From—to—feet belowsurfam <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet belay sudace or feet below surface if>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> a oaquin CouRty 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 /> ,7/ DEPARTMENT USE ONLY 7— <br /> Application Accepted By: /!/!�✓���/�l�l// ',fe/f Date Issued: <br /> 7 <br /> Grout Inspection By/Dates: ,,,��� ) <br /> Destruction Inspection By/Dates /yvi/�fJrfdE/SOA <br /> Facility/Site Information <br /> FA Name FA Address I FA# PR# <br /> FA PE WP Reviewed By 1 1 Work Plan Date <br /> ❑C-57 0057 Aultwnraton for Other to Sign Permit OWofsels Comp ❑Workers camp Waver ❑Encroachment Permit OAa Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: lyypr,�r �L� ��;y�.QA 1."Y&Aty e.f; oJrvvl-s, fv S..iFct <br /> SR TYPE PE SC ?'FElLE INFO AMT REMITTED CHECK# RECV'D BY I DATE I SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 29/72 3f3 $130x Z z z6 S1t'd0��%9 <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />