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r <br /> x �.. SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT $���d��:/� <br /> vv <br /> �tC 1868 Hazelton Avenue, Stockton, CA 95205-6232 JUL � ,.� <br /> • Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:WWW.s'Cehd. m 2 <br /> 0 <br /> 17 <br /> SITE MITIGATION WELL & BORING PERMIT APPLICA TALNFAL <br /> For Wells and Borings Used for Contaminant Investigations and Remediatio oces <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 1201 South Center Street City/State/Zip Stockton,CA,95206 Phone (209)467-1006 <br /> Cross Street West Jackson Street APN 147-160-03 <br /> Property Owner* Jianping Wang Phone (209)390-7218 <br /> Address 1903 Ralph Avenue City/State/Zip Stockton,CA,95206 <br /> C-57 Contractor Advanced GeoEnvironmental,Inc (AGE) License# 680227 Phone (800)511-9300 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA,95215 <br /> Consultant/Sub-Contractor AGE License# 680227 Phone (800)511-9300 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA,95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5.5' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporfWater) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE 3.0" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA NA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS 0.25'Tubing TYPEOFCASING: ❑STEEL ❑PVC KI OTHER Teflon®tubing <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes D No Song Dia: NA Casing Dia: NA Casing Depth: NA <br /> ❑ INJECTION(Air Sparue oxnel ID HAND AUGER GROUT SEAL DEPTH 3.5' TREMIE TYPE TO BE USED: [I AUGERS [I HOSE [I PIPE <br /> ® OTHER 2 soil-vapor wells ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs V-t and V-2 GROUT SPECIFICATIONS Potland Tvce 141 5.6 gallons water per 941b <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 ❑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 /> COMMENTS: See Additional Site Assessment Work Plan dated 09 January 2017(attached) <br /> I hereby certify thatA am authorized to complete this application and that the work will be done in accordance with <br /> Ben Jo In Co ty O�nance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Project Geologist/AGE <br /> Print Name Brian Millman Ir Date 21 July 2017 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: 31, L7 <br /> Grout Inspection By/Dates: 5 Aj O <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information /r <br /> FA Name rew-r`c1� 0 � L,,.—FFA L,, FA f LO Address 1 SO""vi ry l9+'vQ'Y St' FA# �L I�s PR# <br /> FA PE �Ci L 0 WP Reviewed By Work Plan Date <br /> a6:57 ❑G57 Authonzabon far Other to Sgn Permit ]$Worker's Comp ❑Workers Comp Waiver ❑Encroachment Pe mit ❑Access Agreement L9 Lead Agency Approval 711FR <br /> COMMENTS/CONDITIONS:`05 ­�- %-&- ' vAs y�-a'—✓S ,�1 t'C40jr-" c.? <br /> SR PE PE SC FEE INFOAMdT REM! ED CHE K# RECV'D DATE SERVICE REQUEST# INVOICE# <br /> Permit �-90 113 1$152x ;1- y Say -L>ojz L4 -ri1j17 W Qo30y7`} <br /> X10 zm3 5V) ISL x .3 4 L161 -U 011. L -J �I) 117 5f,001j jS5 <br /> 1 EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />