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S A N J O 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 /> Jab Address 1173 North Main Street City/State/Zip Manteca,CA 95336 Phone 610-755.7095 <br /> Cross Street Lancaster Drive APN 216-350-120 <br /> Property Owner' Ralph&C Aquaro Trust Phone 510-755-7095 <br /> Address 1437 Chestnut Drive City/State/Zip Manteca,CA,95336 <br /> C-57 Contractor AdvancedGeo,lnc. License# 1063765 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA 95215 <br /> Consultant/Sub-ContractorAdvancedGeo,lnc. License# 1063765 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA 96215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsAA/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5,15.25 ❑BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(Vaporlwater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 1.5° ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ® SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL [I PVC ❑ OTHER <br /> E9 SOIL BORING 7 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bod g Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Anspae.Ownel ❑ HANDAUGER GROUT SEAL DEPTH 5,15,25 TREMIE TYPE TO BE USED. [I AUGERS [I HOSE 0PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefel Depth is 30 Ft) <br /> WELD SOIL BORING Os Seemap GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 Its sack <br /> DESTRUCTION WORK TO BE PERFORMED: 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 El 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 /> 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 /91ti Title/Company SENIOR GEOLOGIST/A.G.I. <br /> Print Name Daniel Villanueva Date t L . 2 • La <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspecbon By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑G57Authadzadon for Otherto Sign Permit ❑Workers Comp ❑Workers 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 2"1 OM1.17 site Mitigation well Permit Application <br />