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SAN)JOAQL..i <br /> <br />Environmer i 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 />Job Address 108 and 128 East Eleventh Street <br />Cross Street F Street <br />City/State/Zip Tracy, CA, 95376 Phone 916-798-6161 <br />APN 235-173-200 and 235-173-040 <br /> <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 />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />TYPE OF WELL/BORING NUMBER <br />MONITORING 0 <br />EXTRACTION (Vapor/Water) LI <br />SOIL VAPOR PROBE LI <br />El SOIL BORING 4 181 <br />INJECTION (Air Sparse Ozone) Eg <br />OTHER 0 <br />WELL) SOIL BORING IDs <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 12 & 20 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 1.5 inch 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: LI STEEL 0 PVC D OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH 6.5 and 15 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE PIPE <br />GROUT SEAL PUMPED? El Yes E] No (Note: Maximum Freetall 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 />El 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 />0 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 />an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. A <br />Title/Company PROJECT MANAGER/A.G.E. <br />Print Name Daniel Villanueva Date 3 -- 6 - i7 <br />DEPARTMENT USE ONLY <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 FA Address PR# FA# 0 0 ts- ev5444-03 <br />FA PE WP Reviewed By Work Plan Date <br />0 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 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <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 />Signed