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Print Name BRIAN MILLMAN Date 11 JULY 2019 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />EPARTMENT USE ONLY <br />Date Issued: <br />PitkiltvvAaK <br />3! 20 /9 <br />Title/Company PROJECT GEOLOGIST / AGE Signed <br />SA6JOAQUIN <br />cr--) <br />Environmental Health Department <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 35 East 11th Street City/State/Zip Tracy, CA, 95376 <br />Phone (661) 904-2133 <br />Cross Street North El Portal Avenue APN 233-369-16 <br />Property Owner* Levand Family Trust - Paula Levand-trustee phone (661) 904-2133 <br />Address 24692 Sand Wedge Lane City/State/Zip Valencia, CA 91355 <br />C-57 Contractor Slagle Drilling Corporation <br />Address 11345 Trade Center Drive <br />License# 1046151 Phone <br />City/State/Zip Rancho Cordova, CA 95742 <br />916-363-9355 <br />Consultant/Sub-Contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 800-511-9300 <br />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 <br />El EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />I=1 SOIL VAPOR PROBE El MUD ROTARY <br />El SOIL BORING El PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparqe, Ozon0 El HAND AUGER <br />Ei OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? El Yes 12 No <br />GROUT SPECIFICATIONS <br />CI BOLTED TRAFFIC BOX ID STOVE PIPE <br />0 MULTIPLE CASINGS 1:1 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 3 <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />[Z] OVER-BORE DIAMETER of 8.25 inches to depth of 21 eg feet <br />CI PRESSURE GROUT To depth of feet below surface <br />CI EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP J 3 feet below surface or feet below surface if >3 feet <br />WELL IDs MW1, MW2 and MW6 <br /> <br />GROUT SPECIFICATIONS Portland Type II (94Ib + 5.5-6 gallons) <br />TREMIE TYPE TO BE USED E AUGERS HOSE E PIPE <br /> <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 />'Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />FA Name <br />, <br />/I kmei I ruce FA Address 11- „7.-- Z , (e.A.14.A4.4L \ F A# 00 Za.rt 0 PR# 6 5-44063- <br />FA PE 0 5 /1—lo 6.2— WP Reviewed By <br />LA") <br />Work Plan Date ....--/i r."19 <br />CI C-57 ,457 Authorization for Other to Sign Permit CI Workers Comp CI Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement CI Lead Agency Approval CI MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D,BY DATE WELL PERMIT# INVOICE# <br />Permit acio z 31 3 $152x 3 if 5 (/ i/61 .itAi qi WO WP/949 'V <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 />Address 837 North Shaw Road