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SAN 10AQ U I N Environmental Health Department <br /> COUNTY <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <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 1333 Bourbon Street City/State/Zip Stockton,CA 95204 Phone (209)983-6821 <br /> Cross Street West Lane APN 117-030-030-000 <br /> Property Owner* Darren McFadden Phone (209)983-6821 <br /> Address 1333 Bourbon Street City/State/Zip Stockton CA 95204 <br /> C-57 Contractor AdvancedGeo,Inc. License# 1063765 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton CA 95215 <br /> Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zlp Stockton CA 95204 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 feet bsg ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRNEN DIA.OF BOREHOLE 1.5 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS NIA 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(AlrSparce.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 SV1 through SV3 GROUT SPECIFICATIONS Portland type II cement to surf000 grade after collection of samples <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 ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 Feet <br /> COMMENTS:Soil vapor points SV1 through SV3 will be probed to 10 feet bsg for the collection of vapor samples at 5 feet bsg and 10 feet bsg. <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company staff Geologist,AdvancedGeo,Inc. <br /> Print Name Evan Schmidt Date February 25th,2021 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facllit /Site Information q <br /> FA Name �—�+ FA Address �����4 FA# PR# <br /> FA PE 'Z�S" WP Reviewed By /fes Work Plan Date <br /> 57 ❑C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers CompllWaiver []Encroachment Permit ❑Access Agreement Lead Agency Approval FR <br /> COM ENTSlCONDITIONS: <br /> WP TYPE I PE I SC FEE INFO AMT REMITTED CHECKp RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit (]� � , $152x �j S 1 r CJL / 7�S <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-34 0 F 209 464-0138 1�.com <br /> EHD 2MI 08-01-17 :he Midtio We P i pplication <br />