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DEPARTMENT USE ONLY <br />4407 Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />W I - Destruction Inspection By/Dates: <br />Facility/Site Information <br />SAN JOAQUIN <br /> <br />Environmental HeiReMitlYfrit <br />--COUNTY-- <br />Grontness grows hero <br />JAN 2 9 2018 <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations dAsikil43/Akitii&TAL I lEA LTI I <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEPARTMENT <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 308 North Grant Street City/State/Zip Stockton, CA, 95207 <br />Phone 209-467-2667 <br />Cross Street Miner Avenue APN 097-464-19 <br /> <br />Property owner* Charles 8c Donna Skobrak Trust <br /> <br />Phone 209-467-2667 <br /> <br />Address 9947 East Hwy 26 City/State/Zip Stockton, CA, 95215 <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 Advanced GeoEnvrionmental Inc. 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 Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF INELUBORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />LI SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam, Ozone) <br />OTHER <br />WELL/SOIL BORING IDs B11 <br />NUMBER INSTALLATION TYPE <br /> ID HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br />3 to PUSH POINT (GP/ CPT) <br /> El HAND AUGER <br /> 0 OTHER: <br />, B12, B13 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 10 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 1.5" LI MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> <br />CASING THICKNESS TYPE OF CASING: LI STEEL 0 PVC 0 OTHER <br /> <br />CONDUCTOR CASING El Yes El No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH 10 TREMIE TYPE TO BE USED: LI AUGERS LI HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS 6 gallons water per 94 pound bag <br /> <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED <br /> I=1 OVER-BORE DIAMETER of inches to depth of feet <br />WELL IDs El PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE D PIPE <br /> 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San quin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Title/Company Senior Project Geologist/ Advanced GeoEnvironmental Inc. <br />- 71 iç - <br />FA Name 404 lax,re pkg.-0 FA Address .7‘ 0 o (A/V\ Cims/4"- 9t" FA# 00 V330 PR# <br />FA PE cylitii2 WP Reviewed By )-- - Y\ Work Plan Date .51 ç/ I ...7 <br />ErC-57 0 C-57 Authorization for Other to Sign Permit IKorker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement EN"ad Agency Approval l4FR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 0...01,05 -3 13 $152 x --3, 8 (4,s1. -ogut i---)4 _ 2-_10,1 ty v./ e 0031q39 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 ,Site Mitigation Well Permit Application L-)( t_o, gill <br />Signed <br />Print Name Daniel Villanueva <br /> Date