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(a ' <br />s aSaLiJr. / <br />Greatness Orows here ' „IF°. -_,--• <br />— <br />Environmen,_.i Health Department C' al joAou <br />. , 1 1 i <br />authorized <br />unty Ord <br />complete this application and that e work will be done in accordance with <br />ance Codes and Standards, and all oth r applicable California laws. <br />Title/Company STAF GEOLOGIST / AGE Signed <br />I hereby certify tha <br />Joaquin <br />Date ukpi l <br />DEPARTMENT USE ONLY <br />Print Name ne M. Toth <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED D AUGERS ['HOSE I:=1 PIPE <br />ST UCTION METHOD: (CHECK ALL THAT APPLY) <br />DOVER SORE DIAMETER of inches to depth of feet <br />CI PRESS E GROUT To depth of feet below surface <br />0 EXPLOSIV From to feet below surface <br />ID MUSHROOM AP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: *" See work plan "* <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 540 North Hunter Street City/State/Zip Stockton, California Phone (209) 467-1006 <br /> <br />Cross Street East ak Street <br /> APN 139-060-230 <br />Property Owner* Juen <br /> <br />Phone (209) 467-1006 <br /> <br />City/State/Zip Nevada City, California <br />License# 680227 <br />City/State/Zip STOCKTON A 95215 <br />License# 680227 <br />C-57 Contractor ADVANCED <br />Address 837 SHAW ROAD <br />Consultant/Sub-Contractor AGE <br />Address 837 SHAW ROAD <br />OENVIRONMENTAL, INC (AGE) <br />N <br />City/State/Zip STOCK ON, CA 95215 <br />greements or Encroachment Permits <br />Address 11699 Birch le Road <br />\EI) CONSTRUCTION WORK TO BE PERFORM : *Note: Offsite Borings/VVells Require Access <br />Phone (209) 467-1006 <br />Phone (209) 467-1006 <br />DIA. <br />CASI <br />CONDUC <br />GROUT SEAL <br />GROUT SEAL P <br />GROUT SPECIFICA <br />TYPE OF WELUBO RING <br /> <br />NUMBER <br />0 MONITORING <br />ID EXTRACTION (Vapor/Water) <br />ID SOIL VAPOR PROBE <br /> El <br />2 El SOIL BORING <br /> 0 INJECTION (Air Some, Ozone). <br />0 OTHER <br />WELL/ SOIL BORING IDs 6-8 & B-9 <br />OLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />o Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS El HOSE El PIPE <br />IS1 No (Note: Maximum Freefall Depth is 30 Ft) <br />PORTLAND TYPE II <br />INSTALLATION TYP <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />RING DEPTH 25' <br /> <br />F BOREHOLE 1.25" <br /> <br />THICKNESS <br />R CASING El Yes <br />EPTH 24.5' <br />PED? DY <br />NS <br />FA Name FA Address FA# et , 4 i L A. PR# aci-I2 4(17 <br />FA PE ?-ci/ WP Reviewed By 1_, - X Work Plan Date <br />Cq/3 / It <br />0 C-57 0 C-57 Auth ization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 1:1 Encroachment Permit 0 Access Agreement 0 Lead Age Approval 0 MFR <br />COMMENTS/CONDITI, NS: <br />/ / <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152 x <br />COUNTY— <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