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NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well andards. SITE MITIGATION WELL & BORING PERMIT APPLICATION E For Wells and Borings Used for Contaminant Investigations and Remediation z m a:31. 5 f — vil)F Greatness grows he: SA 6.10A0su N Environmentbl Health Department COUNTY— Job Address 2151 Country Club Boulevard City/State/Zip Stockton, CA Phone (209) 823-1400 Cross Street Franklin Avenue APN 123-080-30 Property Owner* 2151 Country Club Boulevard LLC/Rodger Hartley Phone (209) 937-8374 Address P.O. Box 1692 City/State/Zip Manteca, CA 95202 C-57 Contractor All-Well Abandonment License# 848359 Phone (916) 363-9355 Address 3369 Fitzgerald Road City/State/Zip Rancho Cordova, CA 95742 Consultant/Sub-Contractor Advanced GeoEnvironmental Inc. License# 680227 Phone (800) 511-9300 Address 837 North Shaw Road City/State/Zip Stockton, CA 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits INSTALLATION TYPE HOLLOW STEM HAMMER/DRIVEN MUD ROTARY PUSH POINT (GP/ CPT) HAND AUGER OTHER: TYPE OF WELL/BORING NUMBER MONITORING EXTRACTION (Vapor/Water) ID SOIL VAPOR PROBE SOIL BORING 0 El INJECTION (Air Soaroe, Ozone) 11 0 OTHER-soil vapor wells 0 VVELL/ SOIL BORING IDs IVV-1 to IW-11 CONSTRUCTION SPECIFICATIONS BORING DEPTH 30' / 50' El BOLTED TRAFFIC BOX ID STOVE PIPE DIA. OF BOREHOLE 8.25" ID MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA NA CASING THICKNESS .Sch 40 TYPE OF CASING: 0 STEEL El PVC OTHER CONDUCTOR CASING 0 Yes Ei No Boring Dia: NA Casing Dia: NA Casing Depth NA GROUT SEAL DEPTH 6' / 26' TREMIE TYPE TO BE USED: la AUGERS ID HOSE El PIPE GROUT SEAL PUMPED? El Yes and El No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS Portland Type VII 5-6 gallons water per 94Ib of grout DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED CI AUGERS 1:1 HOSE ID PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) I=1 OVER-BORE DIAMETER of inches to depth of feet 1:1 PRESSURE GROUT To depth of feet below surface 1=1 EXPLOSIVES From to feet below surface CI muSHROOM CAP CI 3 feet below surface or feet below surface if >3 feet COMMENTS: Installation of 6 shallow and 7 intermediate injections wells. See Attached CAP/FRP and attached documents. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company Senior Project Geologist Print NameDaniel Villanueva Date 08 November 2017 DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: — Date Issued: 1-- I I ) Destruction Inspection By/Dates: Facility/Site Information FA Name (30 „,4 kv.A-u,--s.4.- FA Address 2-1;1 C/".."' (.. "L‘ k ' FA# QC i3 ,.l, c. PR# 0;4 I 5 1 (I. FA PE PE -_)-cke.C, WP Reviewed By L -X Work Plan Date .3 1 1,1 ID C-57 ID C-57 Authorization for Other to Sign Permit 04orker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement r'ad Agency Approval IIIIVIFR COMMENTS/CONDITIONS: '13 TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# .irmit ,.;11,;.,1 31 :s $152x 5 -1, -IL 294k, 1 L -4 iLlii. 1 ‘..“701J-31L1c. 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 09-(5)1-175.2„3 451, --z--;4u 1 .•e" Site Mitigation Well Permit Application Signed IZ