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SAN JIN Environmental Health Depa tnu em COUNTY Greatness yrows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigationts and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 15SUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 1500 Madruga Road CitylState/Zip Lathrop, CA, 95330 Phone 209-482-1730 Cross Street Guthmiller Road APN 241-030-330 Property Owner* Paul Bottini Phone 209482-1730 Address 1500 Madruga Road City/State/Zip Stockton, CA, 952 209-467-1006C"57 Contractor ADVANCEDGEO, INC. License# 1063765 Phone 209-467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 Consultant/Sub-ContractorADVANCEDGEO, INC. License# 1063765 Phone 2094674006 Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/V1lells Require Access Agreements or Encroachment Permits TYPE OF WELl16ORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (VaporMater) ❑ ® SOIL VAPOR PROBE 2 ❑ INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH 5 and 15 HAMMERIDRIVEN DIA. OF BOREHOLE 1.5" and 3" MUD ROTARY CASING THICKNESS ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA TYPE OF CASING: [I STEEL ❑ PVC ❑ OTHER ® 501E BORING 5 ® PUSH POINT (GPI Mn CONDUCTOR CASING ❑Yes 1`1 No Boring USE ONLY Oia: Casing Dla: Casing no 1h ❑ INJECTION (Air Saarae, omne) ❑ HAND AUGER GROUT SEAL QEPTH 5 and 15 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER El OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELL! SOIL BORING IDs 61-B5,V112 GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack DESTRUCTION WORK TO BE PERFORMED; # WELLS TO BE DESTROYED WELL IQs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED ❑ AUGERS [71 HOSE ❑ P Signed_ Print Name IPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY} ❑OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin Gounty Ordinance Codes and Standards, and al[ other applicable California laws. Tim Cuellar Application Accepted By: _ Grout Inspection ByJDates: Destruction Inspection By1D G'�rilifirlt:ifn Infnrrnnfinn Title/Company SENIOR GEOLOGIST/A.G.I. Date '9 • L a '�` 2v 'Z� DEPARTMENT Date Issued: � d FA Name FA PE 'L�Ir WP Reviewed By S Work Plan Date G57 [1 G57 Authorization for Other to Sign Permit ❑ Worker's Comp [I Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS: QC �q�'� �OQ� \ �A/v" g�'U`fL�o9 G`'C WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit "Z�05 3\ 1$152 x �� W • LZ�A ( (Yw S11 t 1868 E. Hazelton Avenue � Stockton, California 95205 1 T 209 468-3420 � F EHD 29-01 08.01-17 209 464-0138 woof 00V ? 007W�l 1 +www.sjcehd.com e Sile Mitigation Well PerrnitAppli�tion T 209 468-3420 � F EHD 29-01 08.01-17 209 464-0138 woof 00V ? 007W�l 1 +www.sjcehd.com e Sile Mitigation Well PerrnitAppli�tion