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Environmental Health Department <br />PAN <br />Riecz r SITE MITIGATION WELL & BORING PERMIT APPLICATION /1, ft <br />For Wells and Borings Used for Contaminant Investigations and Remediation 4u <br />m <br /> t 2 2018 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AN Jag <br />48 Hours Advance Notice Required For All Inspections fi%ONOUN, <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 Standardru <br />Job Address 375 W. Hazelton Avenue City/State/Zip Stockton, CA 95203 Phone 209-943-7777 <br />Cross Street Scotts Avenue/Commerce St. Ap N 147-120-030 <br /> <br />Property Owner* Eger Properties c/o Bob Long <br /> <br />Phone 209-943-7777 <br />SAN JOACNIN <br />LUUN Y <br />Address 375 W. Hazelton Avenue City/State/Zip Stockton, CA 95203 <br /> <br />C-57 Contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 209-4671006 <br />837 Shaw Road <br />License# 680227 <br />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 />PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes Di No Boring Dia: na Casing Dia: na Casing Depth: <br />El HAND AUGER GROUT SEAL DEPTH 4' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELU SOIL BORING IDs SV-1- rle GROUT SPECIFICATIONS portland type II ge 72 <br />Address <br />Consultant/Sub-Contractor Advanced GeoEnvironmental, Inc. <br />City/State/Zip Stockton, CA 95215 <br />TYPE OF WELL/BORING <br />El MONITORING <br />EXTRACTION (Vapor/Water) <br />17I SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Scarce. Ozone) <br />OTHER 0 OTHER: <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 6.5' Ei BOLTED TRAFFIC BOX 0 STOVE PIPE <br />HAMMER/DRIVEN DIA. OF BOREHOLE 4-inch U MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS 0.25-inch TYPE OF CASING: 0 STEEL 0 PVC la OTHER teflon I na <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />DOVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: see RWQCB-approved work plan dated 06/13/2018 <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 et4)'CA^--- <br />Print Name Timot J4uellar Date CD) 2. ) 10 lir <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: -1 /..10 <br /> <br />/ <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name 5 - 1.—kk,"c,4- FA Addressk -ts- 0 ilcax _ovil trz&FA# 0073 q Dio PR# csrli ocicy.s— <br />FA PE .7) el' WP Reviewed By L—N-' Work Plan Date --2 /e.3 1,$) <br />D C-57 El C-57 Authorization for Other to Sign Permit Ell6kers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement In<e-ad Agency Approval laklfFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit J t :1., I 1,3 $152 x 1 4 i_ - LA./i --1 i- Y -1/..)/a•L <br />4 Ick) 1- 2( —71'1 1 1Y 5C-cci> 71 1°4 <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 <br />)21 5)j <br />Title/company Project Manager/A.G.E.