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SANsd0AQU1, d Environmernta'.LLI Health Department i_ot COUN . . �Ic,;� �` Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 9-1116.3,and the San Joaquin County Well Standards. Job Address 65 East Tenth Street City/State/Zip Tracy,CA,95376 Phone 209.835.4000 Cross Street E Street APN 236-171-120 Property Owner' Dan&Jeannie Borden Trust Phone 209.836.4000 Address PO Box 223639 City/StatelZip Carmel,CA,93922 C-57 Contractor ADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209.467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95216 Consultant/Sub-ContractorADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209-467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 96215 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BorfngsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6.5&10 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Wahx) ❑ HAMMERNRMEN DIA.OF BOREHOLE 1.51nch ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA IR SOILVAPORPROBE 2 ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER ® SOIL BORING 1 0 PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION IAPSpares,Ozonet 0 HANDAUGER GROUTSEALDEPTH 6.5and15 TREMIE TYPE TO BE USED: [I AUGERS [I HOSE 0PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement 6 gallons par 941bs sack 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 [I 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 01 AUGUST 2018 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Z Title/Company PROJECT MANAGERIA.G.E. Print Name Daniel Villanueva Date 1p t/0 —1 '/ //,/ DEPARTMENT USE ONLY Application Accepted By: ngJAC��/`�� Date Issued: Grout Inspection By/Dales: Destruction Inspection By/Dates: mmL '_ Facilit /Site Information FA Name jo FA Address FA# PR# y tw � /✓b�" �iA`s �/,f B• 'G S� Ya1` (1d 253 O e,51146bs FA PE �.� WP Reviewed By Work Plan Date G57 ❑C57Ae01odzalion for Other to Sign Permit RfWorkeesComp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval IfIdFR COMMENTS/CONDITIONS: q�/!o.»�.a.rN 0A So,/ rlgrot-/4-obe s/i4// lee_ A AAa'L-,«e, �w/C 6•Y( Wz% 1 /YY'flr.ry �o�s� WP TYPE PE I SC I FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 2g03- 1313 $152x y s' "' I Z-nRW I PA (,_so-q WFd0397Y8 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHZD 03 08-07-17313 ,/I /52'W X,3 4 /9;10 �1 p! FA g—J7�l a,RQtf S�MigptUjpp Well Permit ,203 J ��•fr /Jr/ 77 �O ra APplicason