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R <br /> SAN JOAQUIN COUNTY 111C.CEIVED <br /> ;y ?�� ENVIRONMENTAL HEALTH DEPARTMENT MAR 31 2017 <br /> • �� `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> EWIRO"ENT <br /> \C)FORe'p i Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.secehd.com A(LI <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION PERMIT/SEROCES TH <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 1045 WEST CHARTER WAY City/State/Zip STOCKTON CA 25206 Phone (209)465-5883 <br /> Cross Street SOUTH STOCKTON STREET APN 163-230-40/-39/-42 <br /> Property Owner* DANTE JOHN NOMELLINI Phone (209)465-5883 <br /> Address 1045 WEST CHARTER WAY City/State/Zip STOCKTON, CA 95206 <br /> C-57 Contractor Advanced GeoEnvironmental,Inc. License# 680227 Phone 209-467-1006 <br /> Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 <br /> Consultant/Sub-Contractor A.G.E. License# 680227 Phone 209-467-1006 <br /> Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6.5 I3 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> [29 SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS 1/4" TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarge.Ozone) ® HAND AUGER GROUT SEAL DEPTH 4.5' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs SV-1&SV-2 GROUT SPECIFICATIONS PORTLAND TYPE II <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ElAUGERS [-IHOSE ElPIPE ElMUSHROOM CAP El3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: SEE WORK PLAN DATED D Jamin iy ri 7o( ;T- <br /> I <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> / S Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Ali Title/Company STAFF GEOLOGIST/A.G.E. <br /> Print Name ERIN ROTTACKER Date 31 MARCH 2017 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: I.� <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address v �9— "D FA# U Z,-3 l'6 PR# �Os�/ <br /> 7 G1 <br /> FA PE G% / WP Reviewed By f.— Work Plan Date //3// '7 Z -7 <br /> 1 11 <br /> C-57 [IC-57 Authorization for Other to Sign Permit Worker's Comp [IWorker's Comp Waiver ❑Encroachment Permit ❑Access Agreement lead Agency Approval / FR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RE�7QUIEST# . INVOICE# <br /> Permit - ,ry "I $139x Z 7 66 Lj Z� �U 7 vt� <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />