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SAN JQAQWN Environmental Health Department COUNTY Greatness grows here. P°4y�elvr SITE MITIGATION WELL & BORING PERMIT APPLICATION e6zvj�® For Wells and Borings Used for Contaminant Investigations and RemediationJU 12 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED $AN JOAQU/Al 2018 rs ce ll ns Application 8 eiebyumad/e�todSaa J,oaquiNCOountyeforRa permitG ltodcoFtOructand and/or thel®orkdescribed THOFPARrT L This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standa/.v Job Address 375 W. Hazelton Avenue City/state/zip Stockton, CA 95203 Phone 209-943-7777 Cross Street Scotts Avenue/Commerce St. APN 147-120-030 Property Owner" Eger Properties c/o Bob Long Phone 209-943-7777 Address 375 W. Hazelton Avenue City/State/Zip Stockton, CA 95203 C-57 Contractor Advanced GeoEnvironmental, Inc. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 Consultant/sub-Contractor Advanced GeoEnvironmental,Inc. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 65 ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 4-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0,25-1nCh TYPE OF CASING: ❑STEEL ❑PVC [TLOTHER Teflon El SOIL BORING El PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes [N No Boring Dia: na Casing Dia: na Casing Depth: na ❑ INJECTION(Air Soarge.ozone) El HAND AUGER GROUT SEAL DEPTH 4' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs S`T-1�� GROUT SPECIFICATIONS portland type II DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: see RWQCB-approved work plan dated 06/13/2018 I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed � , Title/Company Project Manager/A.G.E. Print Name Timot j. uellar Date IC��J Z ' ZQ lei' DEPARTMENT USE ONLY Application Accepted By: A 7 Date Issued: J; Grout Inspection By/Dates: r Destruction Inspection By/Dates: Facilit /Site Information FA Name (." ��y�tii�Jt ;— FA Address �� ! ��z c Lin FA# PR# � FA PE 2 i j G 0 VP Reviewed By L_�' ork Plan Date +-,//j ❑-657 ❑C-57 Authorization for Other to Sign Permit ['Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement 0--lead Agency Approval EI MFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152x - r 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 1 a-l' Site Mitigation Well Permit Application , ,.I S' )-LI4 �t� � I.> � � `1 'l+�i ; � ��tZ SLY 5fCID-71Io_j