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0 OVER-BORE <br />0 PRESSURE GROUT <br />El EXPLOSIVES <br />El MUSHROOM CAP <br />DIAMETER of inches to depth of _ feet <br />To depth of feet below surface <br />From to feet below surface <br />0 3 feet below surface or feet below surface if >3 feet <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT y <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 11ioNM Zgpt <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.ecrclitmi rfArtit <br />r7eAtl x; <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />SEP?vi % -7 <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 />Job Address San Joaquin County Right-of-Way City/State/Zip Stockton, CA, 95205 Phone 209-468-3000 <br />Cross Street Franklin Avenue APN N/A <br />Phone 209-468-3000 Property Owner* San Joaquin County Public Works <br />Address 1810 E. Hazelton Avenue City/State/Zip Stockton, CA,95205 <br />916-363-9355 C-57 Contractor All Well Abandonment License# 848359 Phone <br />Address 3369 Fitzgerald Road City/State/Zip Rancho Cordova, CA, 95742 <br />209-467-1006 Consultant/Sub-Contractor Advanced GeoEnvironmental Inc. License# 680227 Phone <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 WELL/BORING NUMBER INSTALLATION TYPE <br />10IC MONITORING 1 gxl-IOLLOW STEM <br />EXTRACTION (Vapor/Water) ID HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparqe. Ozone! 0 HAND AUGER <br />LI OTHER 1:j OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 25 El BOLTED TRAFFIC BOX 1:1 STOVE PIPE <br />DIA. OF BOREHOLE 8-inch 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> <br />CASING THICKNESS 0.154-inch TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> <br />CONDUCTOR CASING 0 Yes GI No Boring Dia: Casing Dia: Casing Depth <br />GROUT SEAL DEPTH 3 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? g Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs bag <br /> <br />WELL/ SOIL BORING IDs MW-28 <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS ID HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <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 aquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br /> <br />Title/Company Senior Project Geologist/AGE <br />Print Name Daniel Villanueva Date 5"--c - <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: L. yi <br /> <br />Date Issued: /i <br /> <br />n to I I <br /> <br />Destruction Inspection By/Dates. <br />Facility/Site Information <br /> <br />FA Name 6 kt,WeiA,C4 A-"-'4'''''''e.)-- FA Address 2151 to 0•••ect-t.) FA# 0 0 2_1 s, :3 c. PR# c L., i 7 <br />FA PE ',1) ctie. C WP Reviewed By 4 \ Work Plan Date % ii j s <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval D MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit i-4 161 "li G, $139x I i .3 2-2-041 L. . '1, kJ/41 )11 ) 01-1—i 1(eE ) <br />e -003 Sz3 131 X <br />41-11 <br />EHD 29-01 10-26-2015 <br /> Site Mitigation Well Permit Application