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201? <br />Telephone: (209) 468-3420 Fax.. (209) 468-3433 Web: www.sicehd.com <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 />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 />ENVIRONMENTAL HEALTH DEPARTMENT k-41, <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />SAN JOAQUIN COUNTY <br />ikee <br />TYPE OF WELL/BORING <br />El MONITORING <br />EXTRACTION (VaporMater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Sparqe. ()zonal <br />OTHER <br />NUMBER INSTALLATION TYPE <br />1 121 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />WELL/ SOIL BORING IDs MW-21 <br /> <br />Job Address 375 WEST HAZELTON AVENUE City/State/Zip STOCKTON, CA 95203 Phone 209-943-7777 <br />Cross Street HAZELTON AVE. & S. LINCOLN ST APN 147-110-12 <br />Property Owner. EGER PROPERTIES C/O JO EGER Phone 209-943-7777 <br />Address 201 N. FRANKLIN ST., SUITE 300 City/State/Zip TAMPA„ FL 33602 <br />C-57 Contractor GULF SHORE EXPLORATION <br />License# 964224 <br /> <br />Phone 916-939-4117 <br />Address 3383 FITZGERALD RD/ <br />Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL INC. <br />Address 837 SHAW ROAD <br />City/State/Zip RANCHO CORDOVA, CA 95742 <br />License# 680227 Phone <br />City/State/Zip STOCKTON, CA 95215 <br />209-467-1006 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 130 [21 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 8" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS SCHED. 40 TYPE OF CASING: 0 STEEL lai PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 21 No Boring Dia: NA Casing Dia: NA Casing Depth: NA <br />GROUT SEAL DEPTH 115' TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 13 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 1:1 AUGERS 11 HOSE D PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />cl OVER-BORE DIAMETER of inches to depth of feet <br />Li PRESSURE GROUT To depth of feet below surface <br />Li EXPLOSIVES From to feet below surface <br />fl MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: Stt PU.1 GA, — Pt pro,: tra V,0 pis t 0 0/ -7_ _ 7 <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 lemm ' erk..1-b----Title/Company PROJECT MANAGER/ADVANCED GEOENVIRONMENTAL <br />TIMOTHY J. CUELLAR <br />Print Name Date 04/20/2017 <br /> <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name .....__,T exy-i,A FA Address 37$- u. /424 cf.A__ FA# OD Z 3 /../0,6 PR# OSib 6n),S--- <br />FA PE 7M 6 o WP Reviewed By -- Work Plan Date 3 a Vt / 7 .,,, <br />0 C-57 0 C-57 Authonzation for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement El Lead Agency Approval ilriut"FR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE 1 SERVICE REQUEST# INVOICE# <br />Permit '",:. ‘ ) / 3, -,3 $139x ,,1 1 i 3 C/ z-iss . '01— zii 41 ' 7 7 3 <br />$ 7 z- 00 7 7 5 17 <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application