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0 RECEIVED <br /> ip <br /> SAN JOAQUIN COUNTY DEC 03 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 Tdle,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 101 West Beverly Place City]Statemp Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN 233-152-26 <br /> Property Owner- Vicki L. Myers Phone <br /> Address 101 West Beverly Place City/State2ip Tracy, CA 95376 <br /> C-57 Contractor All Well Abandonment, Inc. License# 848359 Phone 916-363-9355 <br /> Address 9245 Beatty Drive Suite A City/State2ip Sacramento, CA 95826 <br /> Consultant/Subcontractor Advanced GeoEnyironmental, Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road City/StateMp Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WEWBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING O HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMNERDRVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POIrff(GP/CPI) CONDUCTORCASING [I Yes El No Boring Da: Casing Dia:_Casing Depth: <br /> ❑ INJECTION Ogrseame Dmsel ❑ 14ANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS El HOSE❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING les GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 dual-completed monitoring well K)OVER-BORE DIAMETER of12 inches to depth of 24 feet <br /> WELLIDsMW-6 ❑PRESSURE GROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS Portland Type II (941b + 5.5-6 gallons)_❑EXPLOSIVES From to_ <br /> feet belay surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below sudace or feet below surface if>3 feet <br /> COMMENTS: SEE WORK PLAN DATED 07 OCTOBER 2015 <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signedp— <br /> }�--� /^G Title/Company PROJECT GEOLOGIST/AGE <br /> � <br /> Print Name BRIAN IVIILLMAN Date 12/02/2015 <br /> DEPARTMENT USE ONLY �r <br /> Application Accepted By: Off/ Date Issued: S/C <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili ]Site Information <br /> FA Name FA Address FA# PRO <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Otherto Sign Pewit ❑Workers Canp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: Ov[rdr1Ttl� W� l2'1kGtr-r�Ylf 4. ZS `f'j �tovf-sr rrr A, / i`r'/ figr.y/ AA--A <br /> �(/kt.Crr.TL J <br /> SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan O /� •� <br /> Permit 2901 313 $130x I 13G IZ (� LIvIR /z 3/3 -sem( N15WI/ <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />