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ak&C� SANolJOUL . ] Environmen ! Health Department COUNTY Greatness grows here. 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 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 City of Stockton ROW near 2121 and 2113 Phelps City/State/Zip Stockton,CA,95206 Phone 209-937-8444 Cross Street Spring Street APN n/a Property Owner* City of Stockton Phone 209-833-7387 Address 345 North EI Dorado Street City/State/Zip Stockton/CA/95202 C-57 Contractor Slagle Drilling Corp. License# 1046151 Phone 209-467-1006 Address 3369 Fitzgerald Road City/State/Zip Rancho Cordova,CA 95742 Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209-467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 ® HOLLOW STEM BORING DEPTH 50 ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8.25 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0.214 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 20 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED E]AUGERS [:]HOSE [IPIPE [-]MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS:SEE RWQCB APPROVED WORK PLAN DATED 01 AUGUST 2018 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San J quin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company PROJECT MANAGER/A.G.E. Print Name Daniel Villanueva —Date �2 � - DEPARTMENT USE ONLY Application Accepted By: Date Issued: J Grout Inspection By/Dates: / /` Destruction Inspection By/Dates: Facilit /Site Information FA Name S � FA Address uZZ S ��rr�O�-v-?nP'� FA# 001-IS(?-8 PR# L)LyggL`1 FA PE (� WP Reviewed By �,x Work Plan Date ' 130 //J, p ❑C-57 57 Authorization for Other to Sign Permit orker's Comp El Worker's Comp Waiver ®'Encroachment Permit [I Access Agreement Dead Agency Approval a MFR COMMENTS/CONDITIONS: gtk M ny-t eL WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit )�I 11� $152 x z 304 M1,Z IL'X -74 I Gl V4003914019- 1868 E. Hazelton Avenue I Stockton, California 95205/1 T 209 46(8-3420 1 F 209 464-0138 1 www.sjcehd.com p EHD�9C-01�Qa-01-17 ♦ 5 r�� , tSz�c3 "� —1 P� l• / �`�t ��G S(4 000t%tion Well l'�—�, it Application