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4, RECE WED APR 0 2017 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 ONM Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.gNER ENTAL HEALTH RAU/SERVICES SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Standards. Job Address 3 East 11th Street City/State/Zip Tracy, CA, 95376 Phone (800) 511-9300 Cross Street Holly Drive APN 233-369-18 Property Owner* Leyand Family Trust/Levand Bright Family Trust - Trustees, Paula Levand & Joan Konkel Phone (661) 904-2133 C-57 Contractor Advanced GeoEnvironmental, Inc (AGE) License# 680227 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 Consultant/Sub-Contractor AGE License# 680227 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits Address 24692 Sand Wedge Lane City/State/Zip Valencia, CA, 91355 TYPE OF WELL/BORING NUMBER MONITORING 0 HOLLOW STEM EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN SOIL VAPOR PROBE 0 MUD ROTARY Gil SOIL BORING 4 3 PUSH POINT (GP/ CPT) INJECTION (Air Spare°, Ozone) 0 HAND AUGER 0THER 0 OTHER: WELL/ SOIL BORING IDs CASING THICKNESS TYPE OF CASING: 0 STEEL U PVC 0 OTHER CONDUCTOR CASING 0 Yes 3 No Boring Dia: NA Casing Dia: NA Casing Depth: NA GROUT SEAL DEPTH IP 40' TREMIE TYPE TO BE USED: 3 AUGERS 0 HOSE El PIPE GROUT SEAL PUMPED? 0 Yes III No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS Potland Type I/II 5-6 gallons water per 94Ib P73 S- 171 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS BORING DEPTH 20-40' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE DIA. OF BOREHOLE 1.5" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA NA DESTRUCTION METHOD: (CHECK ALL THAT APPLY) DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE 0 OVER-BORE 0 PRESSURE GROUT 0 EXPLOSIVES 0 MUSHROOM CAP DIAMETER of inches to depth of _ feet To depth of feet below surface From to feet below surface El 3 feet below surface or feet below surface if >3 feet COMMENTS: See Preliminary Site Assessment Work Plan, dated 02 January 2015 and CVRWQCB Approval letter dated 29 July 2016 (GeoTracker). 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. Signed Title/Company Project Geologist / AGE Print Name Brian Millman Date 19 April 2017 DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: L Destruction Inspection By/Dates: Facility/Site Information Date Issued: 2(7 // 7 67/ Jill &r---.-_•z-01 / A7 z- /4 FA Name / -- 1 ,t FA Address , , ,.. ),:i 1 , FA# ', -2- --- J ..? P R# 0 s 77 / g 7 FA PE WP Reviewed By " 't,it<=--,-- Work Plan Date // •/. /Is' 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 0 MFR COMMENTS/CONDITIONS: . k ?--- hite-4' iCt.', '.,: a 1/1.1/P..i( i.r./ k:-.4:‘,:'4-c_.,-' k. '14:2/ / 6 4.74' /_-V ' A' .‘ C&-f kt^ SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit , $139x .1 I -7 - zz --5) i`-Wz-41 'C--) 77c 2 00 7 7 z-q EHD 29-01 10-26-2015 Site Mitigation Well Permit Application