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Aa`'•a SAN JOAQUIN COUNTY _ ENVIRONMENTAL HEALTH DEPARTMENT 4 �•• 1868 Hazelton Avenue, Stockton, CA 95205-6232 ��4•.- :P• Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.com \IFORa 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 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 9-1115.3,and the San Joaquin County Well Standards. Job Address COS ROW on Stanislaus and Charter WayCity/State/ZipStockton, CA, 95206 Phone 209-937-8444 Cross Street Stanislaus Street/Charter Way APN N/A Property Owner" City of Stockton Phone 209-467-0305 Address 425 North E1 Dorado Street City/State/Zip Stockton, CA, 95202 C-57 Contractor All Well Abandonment License# 848359 Phone 916-363-9355 Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA, 95742 Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor(Water) ❑ R MMER/DRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USER ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FI) WELL]SOIL BORING IN GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 ®OVER-BORE DIAMETER of 8 inches to depth of 49 feet WELL IDs MW-5, MW-6 and MW-11 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ElAUGERS (:1HOSE ElPIPE ElWSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: See work plan for additional details; two wells are installed on the east side of Stanislaus Street and one well is installed on the North Side of East Charter Way. 11>7\ycertify that I am authorized to complete this application and that the work will be done in accordance with San Jo in County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Geologist/AGE Print Name Daniel Villanueva ) �� I <'1C� - wiee'( Z kc'Lvt� DEPS t" Application Accepted By: � F�, /dl�3r�v f v\ ( ��•CD j — trN t Grout Inspection By/Dates: .11rn,'-( ! 1 Is"it 6 I� _ `� Destruction Inspection By/Dates: 11A, 1'j^�� _ -�"` J W V) Facility/Site Information FA Name FA Address _ FA PE WP Reviewed By W- ❑C-57 ❑G57 Aulhorization for Olher to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Perm t ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTSJCONDITIONS: y1.XS CVCk Iy��V' Yt Ori -1 'C+IiLG GY 1 J y �EJ SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Work Plan Permit $130 x 39 D 13`1: /lT 51cell7354)/7 EHD 29-01 6-23-2015 Site Mitigation Well Permit Application