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SAN JOAQUIN Environmenta1Rfi F0tVk&nt C. CJUN I Y Grentness grows Here. AUG 3 0 2019 SITE MITIGATION WELL & BORING PERMIT ARE94"TA M1,L HEALTH For Wells and Borings Used for Contaminant Investigations and Ft li(VF$ 613RNICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -_ 48 Hours Advance Notice Required For All Inspections 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 715 N. Hunter Street City/State/Zip Stockton, CA 95202 Phone 209-483-9999 Cross Street Hunter St. & Park Street APN 139-054-090 Property Owner*Dennis F. Erardi ETAL Phone 209-483-9999 Address P.O. Box 691000 city/statelZip Stockton, CA 95269 C-57 Contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 ConsultanUSub-Contractor License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offske Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6 USOLTEDTRAFFICBOX ❑STOVE PIPE ❑ EXTRACTION(VaporrWater) ❑ HAMMERNRIVEN DIA.OF BOREHOLE —4'❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA na [I SOIL VAPOR PROBE 2 0 MUD ROTARY CASINGTHICKNESS 0.25-TNCHTYPEOFCASING: ❑STEEL ❑PVC IM OTHER to 011 n ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING 0Yes [XNo SorigDla: na casingnia: na Casing Depth: na ❑ INJECTION(AYSouoa.osona) 15 HANDAUGER GROUTSEALDEPTH 4 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes W No (Nate:Ma)dmum Freefall Depth is 30 Ft) WELL]SOIL BORING IDs�VI, SV-2 GROUT SPECIFICATIONS Portland Type II r .Lrl cw- Tlot C*tuw DESTRUCTION WORK TO BE PERFORMED: �l►yL/i9 DESTRUCTION METHOD: (CHECK ALL THAT APPLYI q WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑PRESSUREGROUT To depth of_feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feel below surface t TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS: SEE RWQCB-APPROVED WORKPLAN DATED 06 JANUARY 2019 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with SaBJoaagquin county Ordinance Codes and Standards,and all other applicable California laws. Signed / /�. \W7r_co Title/Company PROJECT MANAGER/A.G.E. Print Name TIMOUiY J. CUELLAR Date p$• !q — %01� DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Z u/ Destruction Inspection By/Dates: 13 Facilit /Site Information I,, FA Name IA a FA Address �l 11). ' unSGY FA# �3 14 PR# Q��Z FA PE 2 q 6 o P Reviewed By 1e/A / l�.yj P� ork Plan Dale11 G57 ❑G57 Au Mdzadon f"Other 10 Sign Perms ❑WorkelsComp ❑Workers Comp Waiver ❑Encroachment Permh ❑Accesslgreemenl ❑Lead Agency Approval ❑MFR COM E TSICONDITIONS: 54lih7+ ';&P •,f� "l 14i r\ �' 40,15 'zY o+C WP TYPE PE SC FEE INFO 1/AMT REMITTED CHECK# REUCV-D BY I DATE WELL PERMIT# INVOICE# Permit I�� 3 $152x a �Ol Z63T1 % I/1j 9 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 0"1.17 �7^,-Vt5wgatbn Well Permit Application C %�1�