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TYPE OF WELL/BORING NUMBER <br />MONITORING 0 <br />EXTRACTION (Vapor/Water) 0 <br />El SOIL VAPOR PROBE 0 <br />El SOIL BORING 14 <br />El INJECTION (Air Sparse, Ozone( <br />OTHER 0 <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />WELL/ SOIL BORING IDs B1 through B14, <br />Environmental Health <br />RECEfitED <br />JAN 1 0 2018 <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIMIVIRONMENTALHEALTH <br />For Wells and Borings Used for Contaminant Investigations and RemediaticeERMIT/SERVICES <br />SANAAQUIN <br />COUNTY <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <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 1011 SOUTH CHEROKEE LANE City/State/Zip LODI, CA 95240 Phone (209) 467-1006 <br />Cross Street DELORES STREET APN 047-400-07 <br />Phone (209) 467-1006 Property Owner* DICKIE A GUTHRIE TRUST et al. <br />Address 1011 SOUTH CHEROKEE LANE City/State/Zip LODI, CA 95240 <br />(209) 467-1006 C-57 Contractor ADVANCED GEOENVIRONMENTAL, INC (AGE) License# 680227 Phone <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />(209) 467-1006 Consultant/Sub-Contractor AGE License# 680227 Phone <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 20' 0 BOLTED TRAFFIC BOX <br /> <br />0 STOVE PIPE <br />DIA. OF BOREHOLE 2" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes RI No Boring Die: Casing Dia: <br />GROUT SEAL DEPTH 19.5, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes gj No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS PORTLAND TYPE II <br />Casing Depth: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED I: AUGERS I:I HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: SEE WORK PLAN DATED 04 JANUARY 2018 <br />(hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />. Sah Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />I A\ Signed A 01/4.C4.4A„,_ <br />Print Name ERIN ROTTACKER Date 04 JANUARY 2018 <br />Title/Company STAFF GEOLOGIST / AGE <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dat <br />Facility/Site Information <br />DEPARTMENT USE ONLY <br />Date Issued: <br />Ot i At 1 63 )6q,0 /6.1a)61,18.8 L-)( 2hity vv/ <br />FA Name .3 i D Aao FA Address / 0// ..S, . acif o gi A__ FA# 00 zit I. 5 r PR# os-I,28,-07 <br />FA PE 7-- c721r.7 WP Reviewed By <br />44/.--- / <br />Work Plan Date .V.SlAr / <br />Agency Approval em FR El/57 0 C-57 Authorizabon for Other to Sign Permit a‘Orker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit Z40.5-- 3/ 3 $152 x:....3 4.-SZ=. Z '73-7 v4S7 Ocro3 Ti 03' <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wvvw.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />lie 7-105