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Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: 41A-4/ 14 <br />PARTM ENT USE ONLY <br />SAI\GJOAQbIN Environmemal Health Department <br />COUNTY -- <br />Greatness grows here. <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 />Lei <br />0.4 <br />'LIFOPS- <br />Job Address 128 East Eleventh Street City/State/Zip Tracy, CA, 95376 Phone 916-798-6161 <br />Cross Street F Street APN 235-173-040 <br />Property Owner* Peter Navarra <br /> <br />Phone 209-833-7387 <br /> <br />Address 3220 Northrop Avenue City/State/Zip Sacramento, CA 95864 <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 />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 12 <br />TYPE OF WELL/BORING NUMBER <br />D MONITORING 0 <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />kg SOIL BORING 2 0 <br />El INJECTION (Air Spam. Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS ID MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: ID STEEL I=1 PVC El OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 13 HOSE El PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DIA. OF BOREHOLE 1.5 inch <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH 12 <br />GROUT SEAL PUMPED? 0 Yes 0 No <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 El AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: SEE RWQCB APPROVED WORK PLAN DATED 01 AUGUST 2018 <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 el " 3 <br />FA Name 00...A.akir-o..rev/114N FA Address taY "'"'44 I V21 g - 14$^1 FA# 00 2-61 rz_ PR# ost_4 4 3 ,..3 <br />FA PE 2°1 512 WP Reviewed By 1— ")( Work Plan Date Niel" /0 <br />12r6d 7 CI C-57 Authorization for Other to Sign Permit Igt‘c:rker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement E1 Lead Agency Approval EOM< <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 7J1A6 10 $152x 2- ct ao`i - _ 1-51,L1 L ( <br />ci H i 0 <br />W1,0074%03 <br />1868 0azet Avenue I iOCktOfl, alif rnia 95 2 8-342o 1 g 46 .sjcehd.com <br />Signed <br />Site Mitigation Well Permit Application EHD 29-01 08-01-17