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RECEIVED SAN JOAQUIN MAR 2 8 20 gnvironmental Health Department - COUNTY-- ENVIRONMENTAL HEALTH G re° tnnsc ,7rnvic PERMIT/SERVICES SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 435 North Harrison Street City/State/Zip Stockton, CA, 95203 Phone 209-762-2753 Cross Street Fremont Street APN 081-371-08 Property Owner* Roberto Merlos Trust Phone 209-762-2753 Address 435 North Harrison Street C-57 Contractor Advanced GeoEnvironmental Inc. City/State/Zip Stockton, CA, 95203 License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 Consultant/Sub-Contractor Advanced GeoEnvrionmental Inc. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS BORING DEPTH 5' and 12' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE DIA. OF BOREHOLE 1.25" and 3" 0 MULTIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA CASING THICKNESS 1/4" TYPE OF CASING: 0 STEEL 0 PVC Et OTHER Teflon Tobin TYPE OF WELUBORING NUMBER 0 MONITORING 0 HOLLOW STEM 171 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN SOIL VAPOR PROBE I 0 MUD ROTARY a SOIL BORING 2 a PUSH POINT (GP/ CPT) INJECTION (Jr Souse. Ozone) CU HAND AUGER OTHER 0 OTHER: WELL/ SOIL BORING Ds B I , B2 and SV-1 CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: GROUT SEAL DEPTH 5 and 12 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes In No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS 6 gallons water per 94 pound bag DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED El AUGERS ID HOSE El PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 1:1 OVER-BORE DIAMETER of inches to depth of feet ID PRESSURE GROUT To depth of feet below surface E EXPLOSIVES From to feet below surface ID MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with ------"".\ San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company Senior Geologist/ Advanced GeoEnvironmental Inc. Print Name Daniel Villanueva Date 5 • 2.8 • M DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information Date Issued: 14 t't) ytit kte."7-4-- FA Name ‘43,,,r‘ A % c,., 4N--4-4- 1-4.11 FA Address q -sc 11/4; itoor r.is 0,, _i- FA# 0 0 2,,is-c, c- PR# 059 2...g 00 FA PE a et, s--t) WP Reviewed By I- •X Work Plan Date -3 fz..„,i J , k U C-57 0 C•57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval El/MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit ,Z;t-i u ,s >1 ? $152x ; b Lt._-C i,- X LA I 0. i t ir-AV44441:111* 1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application Li w e ').,Ct03 hc 3X 3 .4 ILI 0 IC 1 L 'I1ti tij s fe_c; &ti Signed