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• • RECEIVED <br /> SAN .JOAQUIN COUNTY DEC 03 <br /> i ENVIRONMENTAL HEALTH DEPARTMENT 2015 <br /> t 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br /> i..D.Rsa <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:Www.sicehd.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 /> Job Address 110 West Beverly Place CitylStateop Tracy, CA 95376 Phone 800-511-9300 <br /> Cross Street Holly Drive APN 233-153-12 <br /> Property OwneP Mark Church Phone 209-814-2493 <br /> Address PO Box 121 CitylStatelZip Tracy, CA 95378 <br /> C-57 contractor All Well Abandonment Inc. License# 848359 Phone 916-363-9355 <br /> Address 9245 Beatty Drive Suite A City/State/Zip Sacramento CA 95826 <br /> Consultant/Sub-contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br /> Address 837 North Shaw Road citylStatemp Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Bo ingsiWells Require Access Agreements or Encroachment Permits <br /> TIDE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLT ED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMJater) ❑ HAMMERIDWVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA <br /> ❑ SCILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PJC❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes 0N Bourg Dia: Casing Dia: Casing Depth: <br /> EIINJECTION mkcvQgmgl ❑ HANDAUGER GROUT SEALDEPTH TREMIE TYPE TO BE USED ❑AUK�ERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maxinum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD,(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 monitoring well PQ OVER-BORE DIAMETERof 8 indtestodepfhof 14 feet <br /> WELL IDs MW-5 ❑PRESSUREGROUT To depth of_feet below surface <br /> GROUT SPECIFICATIONS Portland T e II 941b + 5.5-6 gallons) ❑EXPLOSIVES From__to_feet below surface <br /> TROUT TYPE TO BE USED AUGERS El HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below sudace 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 /> San Joagufn 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 /> DEPARTMENT USE ONLY <br /> Application Accepted By: /!/</�� 7'TiSB� Date Issued: <br /> Grout Inspection By/Dates: / /F <br /> Destruction Inspection By/Dates /i✓� f! 7 <br /> Facni /Site Information FA# PIR# <br /> FAName FA Address <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑c57 ❑cha57Aulmbmfor Otherto Sign Permit ❑Workers Camp ❑workers Camp Waiver ❑Encioachneit Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# REGV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 29uZ 313 $130k / / /Zsb'G C.v7i( �z�3 /s S,PO�T396� <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />