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SANJOAQLJ Environmer, 41 Health Department <br />COUNTY- <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <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 />Job Address 817 South Center Street City/State/Zip Stockton, California ph one (209) 467-1006 <br />Cross Street South Worth Street APN 147-140-52 <br />Phone (209) 467-1006 Property Owner* California Welding Supply <br />Address 817 South Center Street 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/Welts Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />I=I MONITORING ID HOLLOW STEM BORING DEPTH 20' 1:1 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 1.25" 1:1 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />El SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: ID STEEL 0 PVC CI OTHER <br />ZI SOIL BORING 2 R PUSH POINT (GP/ CPT) CONDUCTOR CASING CI Yes ISI No Boring Dia: Casing Dia: Casing Depth: <br />CI INJECTION (Air Spam, Ozone) ID HAND AUGER GROUT SEAL DEPTH 19.5. TREMIE TYPE TO BE USED: 0 AUGERS CI HOSE CI PIPE <br />CI OTHER 0 OTHER: GROUT SEAL PUMPED? 0 Yes 12:1 No (Note: Maximum Freefall Depth is 30 Ft) <br />WELU SOIL BORING IDs 6-1 & B-2 GROUT SPECIFICATIONS PORTLAND TYPE II <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED El AUGERS El HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: ** See attached standard operating procedures and site plan *" <br />I herby c rtify that.'-am authorized to complete this application and that the work will be done in accordance with <br />San • ounty Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br /> <br />Title/Company STAFF GEOLOGIST / AGE <br /> <br />Date 4/13/18 <br /> <br />Print Name M. Toth <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Date Issued: <br />rtrsik— <br /> <br />• <br />FA Name - ki: % • • "i'1 ‘••-/ 4-la ") 5"41Y if <br />' • ,v,*.uri tev <br />FA Address yii ;„,,,,,riA C.A.A.(,-- Si.-- FA#-- L'Oz-s-t,,, IA" P R# 0 SI/ <br />FA PE ,")- CI) <br />WP Reviewed By L—)‹ Work Plan Date <br />ae-57 0 C-57 Authorization for Other to Sign Permit Eiliorker's Comp 1:1 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement ID Lead Agency Approval IEYMIR <br />COMMENTS/CONDITIONS: ‘4 1:_i-,.. , , , ,, L . . ....5 S <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 4.,q0., $152x )... 4 1 .v-i,u :_s 1-- 4111-) 1 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 , Site Mitigation Well Permit Application <br />)-1 e.,15 s-z,3 4 iTz-x '-1/1-3116-