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SAN JOAQUIN Environmental Health Department <br /> —COUNTY— <br /> . . (�rcn ulss yrolvs h�rc. <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 9-1116.3, and the San Joaquin County Well Standards. <br /> Job Address 615 C STREET CllylStatelZip TRACY,CA 95376 Phone 209.679-8608 <br /> Cross Street C STREET&FAGAN ALLEY APN 235-066-080-000 <br /> Property Owri Finish Line Construction, Inc Phone 209-679-8608 <br /> Address 156BRobert Ct CltylSlatelZip Manteca CA 95337 <br /> C-57 Contractor AdvancedGeo Inc. License# 1063765 Phone 209467-1006 <br /> Address 837 Shaw Road City/Statell Stockton CA 95215 <br /> Consultant/Sub-Contractor A.G.I. License# 1063765 Phone 209467-1006 <br /> Address 837 Shaw Road CitylStateRip Stockton CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELD80RING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIE19tNTIONS <br /> ❑ MONITORING ❑ HOLLOW 7 <br /> STEM BORING DEPTH b ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(ValwM/aleg ❑ HAMMERIDRNEN DIA OF BOREHOLE '"—❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING OU N <br /> ❑ SOIL VAPOR PROBE O MUD ROTARY CASINGTHICKNESS NA TYPE OF CAI [I STEEL [I PVC ❑ O��''THHER ' <br /> ASOILBORING �)�PUSH POINT(GP/CPT) CONDUCTORCASIN� ❑YolgNo BoNy DIX MIF 0% CHN DIX w CaNg Dew: N <br /> ❑ INJECTION NJrSeew.ewwl ❑ HANDAUGER GROUTSEALDEPTH 7.O1 THEME TYPE TTBBE USED: [I AUGERS E3 HOSEV PIPE <br /> ❑ OTHER —�—❑ OTHER: GROUT SEAL PUMPED? 11Y"1XN0 np�OtC Max um Freelal Depth I570 F1) .(� <br /> WELUSOILBORINGIDS O GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(cHECKALL THAT APPLY). <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches todeplh of_feet <br /> WELL IDS ❑PRESSUREGROUT Todeptllof_feetbeloNsurface <br /> GROUTSIP IFICATIONS ❑EXPLOSIVES From_to_feet balm surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE [I MUSHROOM CAP ❑3 feelbdoxsufiace ar feelbdeN sodace if>3feel <br /> COMMENTS: T I C W O m p4r4 p/r I a 7- Z• Z — L D ZO <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 TiBelCompany Senior Geologist <br /> Print Name Timothy) uellar Date 7 t�� ZO LD <br /> DEPARTMENT USE ONLY 0,., <br /> Application Accepted By: Dale Issued: 1 7 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faclll ISIte Information "�� <br /> FA Name FIhtS� GI A.Q. w"&,i FAAddrass 05 C S;4 FAN 1 0tZ6 tj PR# GS4GO+ <br /> FA PE Z9 5© WP Reltemil By Work Plan Dale 0 <br /> G57 ❑C-57 ANhalmtlon kr001erlo Sign Pema I]WekeesComp ❑Workers CompWaMer ❑Encmadlmenl Pemdt ❑AOcess Agreement ❑Lead Agency Approval ❑MFR <br /> COM ENTSICONDITIONS: 5,AII)IIII 1 IrZs Ilikg III rem r'k t 0 �D 4ir InJ411,1 S� d s 13. ?.2 1 1 WI <br /> re s�ws /rife, r-� 40-r s q 10 Ai �ed .g i btel+ d . <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# �INVOICE4 <br /> Permit ZQbS 313 $152X 3c) C ,C 65w •� /?I ZO VIP S� � <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464 01 88rmw v9.SS`j dd.com <br /> EH029010a01-17 Site Mitilation Wen Twirl Applil <br />