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SAN JOAQUIN <br />COUNTY— <br />Environmental Health Departmerni: <br />',$EP 11 REC'D <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 ]-:ours Advance Hodce RequfTed For All lnspections <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 3105 S. El Dorado St City/State/Zip Stockton , CA Phone <br /> 209-466-3554 <br />S. El Dorado St. & W. Ivy St. Cross Street APN 175-120-03 <br /> <br />209-466-3554 <br />Property Owner El Dorado Land Holdings LLC <br /> <br />Phone <br /> <br />Address PO Box 6036 <br />C-57 Contractor Advanced GeoEnviornmental, Inc. <br />City/State/Zip Stockton, CA 95206 <br />License # 680227 Phone 209-467-1006 <br />Address 837 Shaw Road City/State/Zip Stockton CA 95215 <br />Consultant/Sub-Contractor Advanced GeoEnvironmental, Iril_qense# 680227 Phone 209-467-1006 <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 CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM BORING DEPTH 4 - 6.04- IWOLTED TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) El HAMMER/DRIVEN DIA. OF BOREHOLE 3 - jA t....k 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br />X SOIL VAPOR PROBE 2- 0 MUD ROTARY CASING THICKNESS WA TYPE OF CASING: D STEEL 0 PVC 0 OILIER <br />CI SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING D Yes Milo Boring Dia: hillA Casing Dia: N / A Casing Depth: Ai/ A <br />INJECTION (Air Soarae. Ouzel S. HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER 0 OTHER: ail GROUT SEAL PUMPED? 0 Yes o (NotAMaximuin Freefall Depth Is 307„ <br />WELL/ SOIL BORING IDs SV-1 GROUT SPECIFICATIONS A- <br />SV-2 <br />rot-IAA/do Ty t. ac.. <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED p AUGERS 13 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES Front to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: See attached Work Plan, dated April 15, 2017 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Jo quin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed ?oven. . _ Title/Company PROJECT MANAGER/A.G.E. <br />Print Name TIMO i t-I J. CUELLAR Date 08/31/2017 <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br /> <br />/r/10 -7. <br /> <br />Date Issued: <br /> <br />FA Address / u;,.. .. el----((...QcAek FM 0_0 2, 2_13 PR# <br />FA PE //// cZ„...5? 6.-0# WP Reviewed By <br />/4 <br />Work Plan Date ._ it / 7.---h —2 , <br />0 CST 0 C-57 Authorization for Other to Sign Permit 13 worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement Ci Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 9A (:- z, i 3 $152x 0-P0-0 ;-7 3 i t <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />HD 29-01 08-01-17 Site Mitigation Well Permit Application