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REC EIVED SAN JOAQUIN OST 18 20ihnvironmental Health Department —COUNTY— ENVIRONMENTAL HEALTH Greatness grows here. PERMITISERV!CES 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 9-1115.3,and the San Joaquin County Well Standards. Job Address 420 WEST YOSEMITE AVENUE CitylStatelZlp MANTECA, CA 95337 phone Cross Street JESSIE AVENUE ApN 219-312-06 Property Owner" SINGH, PRITPAL&AMRINDER Phone Address 420 WEST YOSEMITE City/State/Zip MANTECA CA 95337 C-57 Contractor ADVANCED GEOENVIRONMENTAL, INC(AGE) License# 680227 Phone (209)467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 Consultant/Sub-Contractor AGE License# 680227 Phone (209)467-1006 Address 837 SHAW ROAD citylstatelzip STOCKTON, CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATIONTYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER 129 SOIL BORING 4 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes KI No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Som,Ozone) ® HAND AUGER GROUT SEAL DEPTH 4,5' TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth Is 30 Ft) WELL/SOIL BORING IDs P-17,P-18, -19,P-20 GROUT SPECIFICATIONS PORTLAND TYPE II 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 ❑PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS ❑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 WORK PLAN DATED 20 JUNE 2017 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed --,(kA , �^'t�P,y/� Title/Company STAFF GEOLOGIST/AGE Print Name ERIN ROTTACKER Date 18 OCTOBER 2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: / / - �/ 7• Destruction Inspection By/Dates: FacilltvISite Information FA Name G n vu'�y FA Address qW wi '4o)"Oa A.,r f, FA# I V U2�15Ct Y PR# I CS` Z.3 L'3 FA PE G, WP Reviewed By 1 Work Plan Date C-57 0C-57 Authorization for Other to Sign Penh Workers Comp ❑WorkerSComp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead AgencyApproval MFR COM M ENTSICON DITIO NS: WP TYPE I PE SC FEE INFO JAMT REMITTED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit .Mej -5%'y $152x '; P `�S`b 13 19 L-A 1G -51III 1r1 P(7U�� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com EHD 28-01 as-01-17 Site Mitigation Well Permit Application ,tt ,�-°tg3 si3 �t5a>< 3 '��sta L351`d 1- �X bltl �n Se�u�lg3z�