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0„�E_ 1,�� � SANoJOAGu N <br /> Environmell aal Health Department <br /> �N L1' vl < <br /> ' I —COUNTY— <br /> �fui \V 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 s tL6 g- <br /> 48 Hours Advance Notice Required For All Inspection <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 4046Wilcox Road City/State/Zip Stockton CA,96216 Phone 206.371.0306 <br /> Cross Street Cherokee Road APN 087-230-080 <br /> Phone 206-371-0306 <br /> Property Owner' Erika Renee Sweet Trust <br /> Address 453 Bloomfield Road License# 68ZIP Sebastopol CA 95472 <br /> C-67 Contractor ADVANCEDGEO INC. <br /> License# 680227 Phone 209.467-1006 <br /> Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 <br /> ConsultantiSub-ContractorADVANCEDGEO,INC. <br /> 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 /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MONITORING ❑ HOLLOW STEM BORING DEPTH <br /> 20 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> [I EXTRACTION(VaporM'aler) [IRAMMERIDRIVEN DIA.OF BOREHOLE 1.5 0 MULTIE OFCASINGPLE SI❑SS[I U❑PVEV❑ OTHER SING DIA <br /> [ISOILVAPOR PROBE EL <br /> ❑ MUD ROTARY CASING THICKNESS <br /> ® SOIL BORING 4 Jim PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bodig Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTIONS ozamel ® HANDAUGER GROUTSFALGROUTSFALDEpTH 72❑Yes ®No (NoIe:IMatimum FE TYPE Ureefal 0eplh BE USED: O3gF�ERS ❑HOSE ®PIPE <br /> [I OTHER ❑ OTHER: <br /> WELD SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement6 gallons r941bs sack <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD. CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface <br /> TREMIE TYPETO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3feet below surface or feet below surface if>3 feet <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 SENIOR GEOLOGIST/A G Ir <br /> Signed <br /> Print Name Daniel Villanueva Date <br /> DEP TMENT USE ONLY � O O <br /> at Issued: <br /> Application Accepted By: <br /> Grout Inspection By/Dates: _ <br /> Destruction Inspection By/Dates: I p^ <br /> Facili /Site Information / FAlf D To L- PR# Dd2'-i3� <br /> FA Name V I1A ' r�, (� FA Address 4O VJ t I o O Plano <br /> ,v iD , 1 Work Plan Date 'LZ Zrf Ui <br /> FA PE WP Reviewed By 1/�,/ <br /> 57 ❑C57 Authorization for other to Sign Permit ❑WwWs Comp ❑Worker's Comp Waiver ❑Enomachmenl Permit ❑Access Agreement ❑,L,ead�Apgency Approval ❑MFR <br /> COMMENTS/CONDITIONS:CJ. µbm� copy G-t` rD31^� W y"�r ti � S 'e—Ai `. <br /> WP TYPE PE SC FEE INFO 11 AMT REMITT/ED �Cy/HECK# RECV'D1/BY D1A�T)11 ,•I pWELL PERMIT# INVOICE# <br /> Permit /0 3 $152 x 4's Gb/ f 7iTlu! �"' VV 1CIO ,y�� <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138a1 www.sicehd.com <br /> sun EHD 29-0108-01-17 <br />