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RECEIVED <br />JAN 1 7 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Cross Street Franklin Avenue <br />Phone 209-823-1400 City/State/Zip Stockton, CA, 95204 <br />Property Owner* Phone 209-937-8444 2151 Country Club Boulevard LLC <br />License* 848359 Phone 916-363-9355 <br />AUGERS El HOSE PIPE TREMIE TYPE TO BE USED <br />, <br />/11 Li, <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br />Telephone: (209) 468-3420 Fax (209) 468-3433 Web: www.sicehd.com PERMIT/SERVICES <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDARI F PFRMIT FXPIRFS 1 YFAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a pRrIllit 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 2151 Country Club Boulevard <br />APN 123-080-30 <br />Address P.O. Box 1692 <br />C-57 Contractor All Well Abandonment <br />Address 3369 Fitzgerald Road <br />Consultant/Sub-Contractor Advanced GeoEnvironmental Inc. <br />Address 837 Shaw Road <br />City/State/Zip Manteca, CA, 95336 <br />City/State/Zip Rancho Cordova, CA, 95742 <br />License# 680227 Phone 209-467-1006 <br />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 <br />13 MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />El SOIL BORING <br />El INJECTION (Air Some. Ozone) <br />El OTHER <br />WELL! SOIL BORING IDs MW-25 thorough MW-27 <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />EJ MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br />DEPARTMENT USE ONLY <br />si "Skil L <br />Date Issued: )/27/1 7 <br />-‘f 1//7 — 2Zii -ti 1/17/17 5-A're-re q.3 <br />Site Mitigation Well Permit Application <br />31P (41,, 2903 523 <br />EHD 29-01 10-26-2015 <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FA# ,0 2 3 y‘:. PR# <br />FA PE WP Reviewed By -/ Work Plan Date I1 Movk, 'IC q. <br />0 C-57 ErC-;-7 Authorization for Other to Sign Permit aliarer's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 10 .12A-d Agency Approval DeFR <br />COMMENTS/CONDITIONS: ,atc.A._ .,44 4,04.-(4 (ciuribi_t let-cyci -/- os e ti.- e(.....--c •A- eicia tits :yea r j," )4-44,.- 30 / AI <br />- 1/4/V9 Ce 4PehYvae Pc-6.0, ,t eccri, <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit 2 (2)4 31; $139 x 5 — ,eizi 7 — LZii z 4,/-1\ /"/ 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 />Sa oaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Senior Project Geologist/AGE <br />Print Name Daniel Villanueva Date 01 te <br />Signed <br />COMMENTS: <br />‘%xtdoi'Y" <br />NUMBER INSTALLATION TYPE <br />3 I2IXHOLLOV5 STEM <br /> El HAMMER/DRIVEN <br /> CI MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />1:1 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 30 and 50 0 BOLTED TRAFFIC BOX 1:1 STOVE PIPE <br />DIA. OF BOREHOLE 8-inch 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS 0.154-inch TYPE OF CASING: 0 STEEL El PVC El OTHER <br />CONDUCTOR CASING ci Yes El No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH 6 and 35 TREMIE TYPE TO BE USED: a AUGERS ID HOSE D PIPE <br />GROUT SEAL PUMPED? 10 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs bag <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS