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SA N'f 0 A 0 U I N Environmental Health Department 4" COUNTY GreotnPss crows herr. RECEIVED SITE MITIGATION WELL & BORING PERMIT APPLICATION AUG 6 3 W8 For Wells and Borings Used for Contaminant Investigations and ryL Remedial- NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r 'R�r�r�°�EN�AL HE4LTH 48 Hours Advance Notice Required For All Inspections PE°R�1T''EIZV!=FS 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 1670 S.Union Street City/State/Zip Stockton,CA 95204 Phone 209-951-8228 Cross Street South Union St. &2nd Street APN 169-030-13 Property Owner* City of Stockton Phone 209-937-8539 Address 400 E.Main Street,4th Floor City/State/Zip Stockton,CA 95202 C-57 Contractor Advanced GeoEnvironmental,Inc. License# 680557 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor A.G.E. License# 680227 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton/CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 10',20',50' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2-inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA na I3 SOIL VAPOR PROBE 2 ❑ MUD ROTARY CASING THICKNESS na TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER na ® SOIL BORING 1 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: na Casing Dia: na Casing Depth: na ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 10',20',50' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IX7 PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes I]No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SV2(ABC),SV3(ABC) GROUT SPECIFICATIONS Portland Type II SV 4(ABC) SV5(ABC) 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 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED []AUGERS ❑HOSE [IPIPE ElMUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: See attached Site Assessment Work Plan I hereby certify that I am authorized to complete this application and that'the work will be done in accordance with �J an J uin County Ordinance.Codes and Standards,and all other applicable California laws. Signed 4 Title/Company Project Manager/A.G.E. Print Name Timothy . ar Date 08/02/2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information �..Ir -, �:, FA Name P FA Address T O l 5 A,�P✓7� t,Jc1 FA# Z L'" 1 PR# ©S ia3k FA PE .1A WP Reviewed By / Work Plan Date t Q'C-57 ❑C-57 Authorization for Other to Sign Permit orkees Comp []Worker's Comp Waiver []Encroachment Permit []Access Agreement []Lead Agency Approval B-MVR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE j WELL PERMIT# j INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Site Mitigabon Well Permit Application