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oRa`'ty SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N; < 1868 Hazelton Avenue, Stockton, CA 95205-6232 �,q•—� �Q• Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sicehd.com �%PORN SITE MITIGATION WELL & BORING PERMIT APPLICATION 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 COS ROW on Stanislaus and Charter WayCitylState2ipStockton, CA, 95206 Phone 209-937-8444 Cross Street Stanislaus Street/Charter Way APN N/A Property Owner"' City of Stockton Phone 209-467-0305 Address 425 North El Dorado Street City/State/Zip Stockton, CA, 95202 C-57 Contractor All Well Abandonment License# 848359 Phone 916-363-9355 Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA, 95742 Consultant/Sub-Contractor .Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:❑STEEL❑PVC❑OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes❑No Boring Dia: Casing Dia Casing Depth: ❑ INJECTION[Airsoarm.Ozonel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS El HOSE[3 PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IN GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ®OVER-BORE DIAMETER of 8 inches to depth of 4 9 feet WELL IDs MW-5, MW-6 and MW-11 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [IAUGERS [:1HOSE [:1PIPE [IMUSHROOM CAP El3 feet below surface or feet below surface if>3 feet COMMENTS: See work plan for additional details; two wells are installed on the east side of Stanislaus Street and one well is installed on the North Side of East Charter Way. I y certify that I am authorized to complete this application and that the work will be done in accordance with San Jo in Co_unty Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Geologist/AGE Print Name Daniel Villanueva Date 10/27/2015 DEPARTMENT USE ONLY Application Accepted By: ///��/?� f/�'Gld��'✓7�''� Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facifi /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By I Work Plan Dale LIC-57 ❑G57 Aulhodzation for Other to Sign Permit ❑Worker's Camp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan 7 Permit Z`)� 31 j $130x -5/�li�)L'J75�)/ EHD 29-016-23-2015 Site Mitigation Well Permit Application