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e, <br />SAN JOAOL.N <br />--COUNTY— <br />Greatness grows here <br />Environmei_d1 Health Department <br />RECEIVED <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION FE 8 II 2018 <br />For Wells and Borings Used for Contaminant Investigations and Remedittist <br />ONMEN FAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <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 4025 Coronado Avenue City/State/Zip Stockton, California Phone (209) 467-1006 <br />Cross Street Enterprise Street ApN 115-300-25 <br />Phone (209) 467-1006 Property Owner* J H Simpson Co. Inc. <br />Address 4025 Coronado Avenue City/State/Zip Stockton, California <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 Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1:1 MONITORING D HOLLOW STEM BORING DEPTH 15' 12 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 EXTRACTION (Vapor/Water) ID HAMMER/DRIVEN DIA. OF BOREHOLE 1.25" 0 MULTIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA <br />ID SOIL VAPOR PROBE 12 MUD ROTARY CASING THICKNESS TYPE OF CASING: ID STEEL 0 PVC ID OTHER <br />IN SOIL BORING 5 w PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes KI No Boring Dia: Casing Dia: Casing Depth: <br />ID INJECTION (Air Spam, Ozone). 12 HAND AUGER GROUT SEAL DEPTH 14.5' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE D PIPE <br />D OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes Cia No (Note: Maximum Freefall Depth is 30 Ft) <br />WELL/ SOIL BORING IDs SV1 through SV5 GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br /> <br />VOUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 1:1 PIPE <br /> <br />COMMENTS: SEE WORK PLAN DATED 08 February 2018 <br />reby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joa n C unty Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company •STAFF GEOLOGIST / AGE <br /> <br />DEPARTMENT USE ONLY <br /> <br />241-1 I (P Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />Signed <br />Print Name Ren . Toth Date <br />FA Name 71-i S , e,-,04,,A C L, c;,_,L , FA Address <br />i <br />,-.)-iicC, joy_t L tek-vp-4.-, FA# <br />1 .. <br />CD L 41 61 PR# <br />FA PE aq CD WP Reviewed By L . Y- Work Plan Date 2-- I I' 1 CY <br />I!(C'-57 0 C-57 Authorization for Other to Sign Permit ria4O rker's Comp 0 Workers Comp Waiver 0 Encroachment Permit ID Access Agreement 0 Lead Agency Approval EiltR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC ' FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit :..lcit.> 3 i 3 $152x 3 A .,k/S1,, <br />,.._ <br />-L5Vi 3 L --)( 2 I ii Id -,,J e 003 1 A:210 <br />186b E.iiazettorr Avenue btockton, California 95 -6 ref 209 468-3420 F 21J9 464-0138 wWw.sjcehd.com S-05 x: L—A_ L 6C <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application