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0. • <br />• <br />:‹1 <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED AUGERS HOSE E1 PIPE <br />COMMENTS: *SEE SITE PLAN <br />DEPARTMENT USE ONLY <br />Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: L--)c OEN- 62_ <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />1,31 SOIL BORING <br />INJECTION (Air Spare. Ozone( <br />0 OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 13,1 HOLLOW STEM BORING DEPTH 10' El BOLTED TRAFFIC BOX CI STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 1.5" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />El MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 1:1 OTHER <br />CONDUCTOR CASING I=1 Yes El No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 1:1 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 1=1 Yes No (Note: Maximum Freefall Depth is 30 Fl) <br />GROUT SPECIFICATIONS Portland Type 11 - 6 gallon per 94 lb bag <br />A .csi PUSH POINT (GP/ CPT) <br /> N HAND AUGER <br />0 OTHER: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />E OVER-BORE DIAMETER of inches to depth of feet <br />12 PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 3 feet below surface or feet below surface if >3 feet <br />ereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Signed <br />Print Name ene Toth <br />San In b nty Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Advanced GeoEnvironmental, Inc. <br />Date 12/19/2017 <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />RECEIVED <br />DEC 22 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: HEALTHwww.sicehd.cfiNVIRONMITENETRALvIcFs <br />SITE MITIGATION WELL & BORING PERMIT APPLICATI <br />is <br />ff <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 2422 South California Street <br />Cross Street East 9th Street <br />Property Owner* Elwood Investments, Inc. <br />City/State/Zip Stockton, California Phone <br />APN 167-070-30 <br />Phone <br />Address 34 Alamo Square, Suite 200 <br />C-57 Contractor Advanced GeoEnvironmental, Inc. <br />Address 837 Shaw Road <br />Consultant/Sub-Contractor Advanced GeoEnvironmental, Inc. <br />Address 837 Shaw Road <br />City/State/Zip Alamo, California <br />License# 680227 Phone 209-467-1006 <br />City/State/Zip Stockton, California <br />License# 680227 <br />Phone 209-467-1006 <br />City/State/Zip Stockton, California <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />FA Name c..\ lei (1__ FA Address Zji .z.)-z_ g (64.4pn:;=4„FA# ti7ez,47 Li 1 1 PR# Oci z <br />FA PE <)2 s---0 WP Reviewed By Work Plan Date <br />C-57 0 C-57 Authorization for Other to Sign Permit lik4rkers Comp 0 Worker's Comp Waiver 0 Encroachment Permit 1:1 Access Agreement 10 Lead Agency Approval FR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SE-RV10E T# INVOICE# <br />Permit oos- 31 3 $139 x 'Z— ...1 50 11 v7-701 v------ i is, a OD 37 17 1 <br />bA) 710 <br />END 29-01 10-26-2015 Site Mitigation Well Permit Application