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Broadway & Fremont Street APN 142-240-06 Cross Street <br />Phone 925-988-9800 Property Owner. John Yandell <br />License# Same as above <br />DEPARTMENT USE ONLY <br />Date Issued: 12-3 Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Environmental Health Dcip§rn <br />ENV/Ro <br />1T 5 20is <br />PE/4/IftiVrAt „ (*Ai <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION viCEs <br />For Wells and Borings Used for Contaminant Investigations and Remediation <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 />RECE/ <br />Job Address 1002 N. Broadway Avenue P hone City/State/Zip Stockton, CA Ph 925-988-9800 <br />Address 360 Industrial Ct, <br />C-57 Contractor Advanced GeoEnvironmental, Inc. <br />Address 837 Shaw Road <br />City/State/Zip Benecia, CA 94510 <br />License# 680227 <br />City/State/Zip Stockton, CA 95215 <br />Consultant/Sub-Contractor <br />Address Same as above <br />Same as above 209-467-1006 Phone <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />El MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />EI SOIL BORING 2 0 <br />INJECTION (Air Spam. Ozone) 0 <br />OTHER <br />WELL/ SOIL BORING IDs B1 & B2 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 15 feet 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 2-inch El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS na TYPE OF CASING: D STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes ID No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH 15 feet TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE El PIPE <br />GROUT SEAL PUMPED? 0 Yes 9 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Portland Type II <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS El HOSE El PIPE <br />El OVER-BORE <br />CI PRESSURE GROUT <br />0 EXPLOSIVES <br />0 MUSHROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />El 3 feet below surface or feet below surface if >3 feet <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />COMMENTS: <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 in County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />Print Name Name TIMOTHY J. UELLAR Date 02/05/2018 <br />FA Name 1,...r4LAri -TY' <br />FA Address V,202_ I's! v oL",-,/ tr.k..-FA# 0 OV-41-1 V1 PR# Osti 1 s-tici <br />FA PE <br />,-)-C' SI) <br />VVPieviewed By L y Work Plan Date <br />El C-57 V-57 Authorization for Other to Sign Permit E(Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit In Access Agreement 0 Lead Agency Approval ErM;R <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit -2AK 3' $152x I '-. C‘ 1-WVA L -*/` -1- i'l- v6 v.) eco3 1' t -13 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />L <br />e " :451, - <br />19-4 •-t 4510 2.mobt lig 4_001 cl -i> <br />PROJECT MANAGER/A.G.E. Title/Company <br />SAN _JOAQUIN <br />1.irrntr)Pcc prowc <br />209-467-1006 <br />Phone <br />City/State/Zip Same as above <br />COUNTY