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SA N : M AQ U I N Environmental 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 330 West Harding Way City/State/Zip Stockton CA,95202 Phone (408)660-7473 <br /> Cross Street N Van Buren Street APN 137-080-010-000 <br /> Property Owner* Batra,Atul Kumar&Suman Phone (408)660-7473 <br /> Address 91 Los Altos Drive City/State/Zip Hollister,CA 95023 <br /> AdvancedGeo, Inc. 1063765 (209)467-1006 <br /> C-57 Contractor License# Phone <br /> Address 837 Shaw Road City/State/Zip Stockton, CA 95215 <br /> Consultant/Sub-Contractor Slagle Drilling Corporation License# 1046151 Phone (916)363-9355 <br /> Address 11345 Trade Center Drive City/State/Zip Rancho Cordova,CA 95742 <br /> CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Saaroe,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 46flbsg(MW-7) <br /> #WELLS TO BE DESTROYED Two 2 8 25 SSftbsg(MW-2) <br /> ( ) KZ DIAMETER of inches to depth of feet <br /> WELL IDS MW-2 and MW4 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS Portlandtypell cement to surface grade ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: Monitoring well MW-2 will be overdrilled to 46 feet below surface grade and monitoring well MW-7 will be overdilled to 55 feet below <br /> surface grade. Both wells will be backfilled to surface grade with Portland type II cement. <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 /> Signed Title/Company Staff Geologist,AdvancedGeo, Inc. <br /> Print Name Evan Schmidt Date February 19th,2021 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />