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/'°A°``° $AN�J0A U N Environmental Health Department <br /> � .i,��.. .� COUNTY- <br /> 1 ai 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 2769 Teepee Drive City/State/Zip Stockton,CA,96205 Phone 949-307.0792 <br /> Cross Street Lance Drive APN 132-080-290 <br /> Property Owner* AlrResource Technologies LLC Phone 209.8364000 <br /> Address 3231-C Business Park Drive#321 City/State/Zip Vista,CA,92081 <br /> C-57 Contractor ADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209467-1006 <br /> Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 <br /> Consultant/Sub-ContractorADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209-467-1006 <br /> Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Otfsile BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10 and 20 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporlWater) ❑ HAMMERIDRNEN DIA OF BOREHOLE 1.51nch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> N SOILBORING 8 N PUSH POINT(GPI CPT) CONDUCTOR CASING [I Yes [I No Boring Dia: Casing Die: Casing Depth: <br /> ❑ INJECTION relrSoame.Ozw N HANDAUGER GROUTSEALDEPTH 10and2o TREMIE TYPE TO BE USED: [I AUGERS [I HOSE NPIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes N No (Note:Maximum Freefall Depth is 30 FQ <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement 6 gallons per 94lbs 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 feel <br /> COMMENTS:SEE RWQCB APPROVED WORK PLAN DATED 01 AUGUST 2018 <br /> 1 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 On� Title/Company PROJECT MANAGER/A.G.E. <br /> Print Name Daniel Villanueva Date <br /> ARTMENT USE ONLY p <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information 7. <br /> FA Name Ar Kt �&W- ies FA Address Z 1 pr FA# O� 2,�j PRO 0�43I <br /> FA PE Z�j C) WP Reviewed By �� Work Plan Dale �/.2 2b I <br /> G57 [143,57 Authorization for Other to Sgn Permit Workers mp ❑Workers Comp Waiver ❑Ewroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COM__MENTSIC•'O'IlNDITIONS: ..fit <br /> rmw <br /> IAJf{/'� in � �G <br /> �ShAfl-�� as2/C ►2'SN, S � �"o oe�;ot'�y r� <br /> v,r, @ <br /> WP TYPE I PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY DATE WELL PEERMIT#I` INVOICE# <br /> Permit 2qq 313 $152x 4 2(4 L,/ ' /�Q J4 $l[f? <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 />