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/z. <br />g <br />0 sANJOAQUIii <br /> COUNTY <br /> EnvironmentacHealth Department <br />RECEIVED Greatness grows here. \-c.-ltaFoe/ <br />SITE MITIGATION WELL & BORING PERMIT APPLICATIOR m <br />IT/SERVICES <br />1 4 <br />HEALTH ENVIRONMENTAL <br />E <br />2019 For Wells and Borings Used for Contaminant Investigations and Remedip <br />at <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 />eft <br />Job Address 1755W. MairrStreet City/State/Zip Tracy, CA, 95376 Phone 209-833-7387 <br />Cross Street Alden Glen Drive APN 232-170-270 <br />Property Owner* Abelino & Decia Valdez Phone 209-833-7387 <br />Address 28065 Blossom Lane City/State/Zip Tracy/CA/95304-8122 <br />C-57 Contractor ADVANCED GEOENVIRONMENTAL, INC. License# 680227 Phone 209-467-1006 <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL, INC. License# 680227 Phone 209-467-1006 <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 WELL/BORING NUMBER <br />El MONITORING <br />EXTRACTION (Vapor/Water) El <br />El SOIL VAPOR PROBE 4 0 <br />El SOIL BORING 6 El <br />INJECTION (Air Soaroe. Ozone) <br />OTHER El <br />WELU SOIL BORING IDs <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 6.5 & 15 ID BOLTED TRAFFIC BOX El STOVE PIPE <br />HAMMER/DRIVEN DIA. OF BOREHOLE 1.5 and 4 inch El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING El Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH 6.5 and 15 TREMIE TYPE TO BE USED: D AUGERS D HOSE 0 PIPE <br />OTHER: GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br /> GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack <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 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />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 />MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company PROJECT MANAGER/A.G.E. <br />Print Name Daniel Villanueva Date / // <br />Signed <br /> <br />DEPARTMENT SE ONLY <br /> <br />col <br /> <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />FA Name V\_ A i <br />rvi tAt r t— erv e.{ FA Address ri 57 ,,,J. 44,..xx__ 5 1--FA# 0 o Lso Lilo PR# 059c4 a 41 <br />FA PE ?A 50 WP Reviewed By /..- /V Work Plan Date \ 3 \\ <br />10/157 0 C-57 Authorization for Other to Sign Permit 13'orkers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 524FR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 00.15 313 $152x 3 4" Lo3 -a35 1 u 51 t I ik, I 1,9 tiJe 00 <br />1868 E. Hazelton Avenue 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 />kAt e -140 3 3-t3 4624 3 2,61c1 LA/ VI /ti sle-0-4)f-cvct