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• • RECEIVED SAN JOAQUIN COUNTY OCT 28 2015 ENVIRONMENTAL HEALTH DEPARTMENT N < 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH q 'P Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www sicehd.caR MMIT/SERVICES C/FOA 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 1700 South EI Dorado Street City/State/Zip Stockton,CA 95206 Phone 209-937-7625 Cross Street 3rd Street APN 167-033-26 Property Owner• San Joaquin Housing Investment Group, LLC Phone 209-937-7625 Address 1209 East 8th Street City/State/Zip Stockton,CA 95206 C-57 Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/ ipStockton,CA 95215 ConsultantfSub-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 BoringsA/Vells Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDIRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El PVC❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 N Bonng Dia: Casing Da: Casing Depth: ❑ INJECTION WrSoame.Omne1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE [I PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:MaDdrnn Freefdl Depth is 30 FU WEW SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 7 P9 OVER-BORE DIAMETER of 1.25 inches to depth of 5-10 feet WELL IDs VP1-VP7 [I PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with r� �S oaqum County Ordinance Codes and Standards,and all other applicable California laws. Signed_ �1fY Title/Company Staff Geologist/Advanced GeoEnvironmental Print Name JennifeH3erigian Date 10/27/2015 /�// DEPARTMENT USE ONLY b Application Accepted By: ///✓.4/ Pl. _ Date Issued: IZ/Io%5 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili (Site Information FA Name FA Address FA# PR# PAPE WP Reviewed By I Work Plan Date EIC-57 ❑C57 Authodzation for Other to Sign PaM.t ❑Workers Camp ❑Workers Comp Waiver ❑Encroachment Perdt ❑Acoess Agreement ❑IEad Agency Approval ❑MFR COMMENTSICONDITIONS: SRTYPEJ PE I SC I FEE INFO JAMT REMITTED CHECK#I RECVD BY I DATE SERVICE REQUEST# INVOICE# Work Plan 2903 152- g3% I 96 119M Cie MOO 73960 Permit 290 2 1313 $130x S xe-`56 112339 601? /o ZzB.rr 5/Z61739x7 EHD 29-016-23-2015 Site Mitigation Well Permit Application