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- <br />SANAA Environmen. Health Department <br />- --COUNTY — <br />' ,.:10,0,,vx• Greatness grows here. RECEIVED <br />SITE MITIGATION WELL & BORING PERMIT APPLicATION 2UI8 <br />For Wells and Borings Used for Contaminant Investigations and flimsgiVi90, RI Al_ HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERWCFS <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 515W. CHARTER WAY City/State/Zip STOCKTON CA Phone 209-464-5780 <br />Cross Street CHARTER WAY & S. LINCOLN ST. APN 147-074-080 <br /> <br />Property Owner* DONALD RODGERS Phone 209-464-5780 <br />Address 11900 South Union Road City/State/Zip Manteca/CA/95339 <br />C-57 Contractor ADVANCED GEOENVIRONMENTAL, INC. License# 680227 Phone 209-467-1006 <br />Address 837 SHAW ROAD <br />Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL, INC. <br />City/State/Zip STOCKTON, CA 95215 <br />License# 680227 Phone 209-467-1006 <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br /> <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 0 HOLLOW STEM BORING DEPTH / 0 ' 0 BOLTED TRAFFIC BOX <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 9 0 MULTIPLE CASINGS D "0 <br /> STOVE PIPE <br />MULTI-LEVEL WELL CASING DIA /44 <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS irJJA TYPE OF CASING: 0 STEEL ID PVC 0 OTHER RSOIL BORING I 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />10 INJECTION (Air Scarce. Ozone) piL HAND AUGER GROUT SEAL DEPTH IC 1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER 10' OTHER: GROUT SEAL PUMPED? 0 Yes prflo (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS ee r 1 /40/ 0 77 pE TM_ <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />OVER-BORE DIAMETER of inches to depth of feet <br /> <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br /> <br />ID PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />MUSHROOM CAP D 3 feet below surface or feet below surface if >3 feet <br /> <br />El AUGERS D HOSE El PIPE <br />COMMENTS: SEE RWQCB APPROVED WORK PLAN DATED 01 AUGUST 2018 <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 <br />149tsY . 04. CUELLAR <br />Title/Company PROJECT MANAGER/A.G.E. <br />Print Name TIM Date CV Sit <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: V /1.44,/i <br /> <br />/ <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name ili,-C. • v ,,w-t i •-'"°.t, StFA Address c--- c .vo, cLA.tis,vi-y,v, v Jr_i FA# c c, 1 c,e,,i, i PR# o_c--2.1 -11., <br />FA PE :)_st 6, 0 WP Reviewed By c...-y Work Plan Date <br />W /. 1 1 k <br />12'6 0 C-57 Authorization for Other to Sign Permit 1:114Orkers Comp 0 Workers Comp Waiver D Encroachment Permit 0 Access Agreement EKSCI Agency Approval alotFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit vic;,., ::, t -,,, $152x i 1 /.L L-I 6') L --e eiltqlek (iJe0o3gR‘xi <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />C2-X L( 9 /0/i6 5-f....co -71