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°G SAN.PJ0AQUINp Environmental Health Department I, COUNTY--- P Greatness grows here. 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 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# ' b St Z2Phone 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 BoringsNVells 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 24ch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA na ® 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 3oame.ozonel ❑ HAND AUGER GROUT SEAL DEPTH 10',20',50' TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE 1x]PIPE ❑ OTHER ❑ OTHER: (lG�ROUT SEAL PUMPED? ❑Yes ©No (Note:Maximum Freefall Depth Is 30 Ft) WELL/SOIL BORING IDs $V ( � /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 ❑PRESSURE GROUT 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 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 San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Project Manager/A.G.E. Print Name Timothy J.Cuellar Date 08/02/2018 D RT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: 1,34, Destruction Inspection By/Dates: Facilit /Site Information FA Name ttc.ltV2(p��.�t FA Address FA# O CZ c PR# Os�A 3 3 Io FA PE Oj 5� WP Reviewed By L_x Work Plan Date ❑C-57 ❑0-57 Authorization for Other to Sign Permitorker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval M4FR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit ( S j3 $152 x f --i 0 v 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application