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Signed <br />Print Name RE 'E TOTH <br />RECEIVED <br />JUN 08 2W? <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: A.A.LwAc..._41c ok <br />i • NONMENTAL HEALTH <br />SITE MITIGATION WELL & BORING PERMIT APPLICATPINT/sERvicEs <br />For Wells and Borings Used for Contaminant Investigations and Remediation <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 308 NORTH GRANT STREET City/State/Zip STOCKTON, CA 95202 Phone (209)465-2667 <br />Cross Street EAST MINER AVENUE APN 139-320-13 <br />Phone (209)465-2667 Property Owner* CHARLES SKOBRAK TRUST <br />Address 947 EAST HIGHWAY 26 City/State/Zip STOCKTON, CA 95202 <br />(209)467-1006 C-57 Contractor ADVANCED GEOENVIRONMENTAL License# 680227 Phone <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />(209)467-1006 Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL License# 680227 Phone <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />VI SOIL BORING <br />INJECTION (Air Sparqe, Ozone( <br />El OTHER <br />WELL/ SOIL BORING 10s <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> IN HOLLOW STEM BORING DEPTH 10' 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 1.5" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _Ig) PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes Eg No Boring Dia: Casing Dia: Casing Depth: <br /> Ig HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 0 PIPE <br /> 0 OTHER: GROUT SEAL PUMPED? 0 Yes Ej No (Note: Maximum Freefall Depth is 30 Ft) <br /> GROUT SPECIFICATIONS PORTLAND TYPE II - 6 gallon per 94 lb bag <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 12 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />fl MUSHROOM CAP IJ 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />SEE WORKPLAN DATED 05 MAY 2017 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joa ounty Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company STAFF GEOLOGIST/ ADVANCED GEOENVIRONMENTAL <br />Date <br />DEPARTMENT USE ONLY <br />M <br />Application Accepted By: <br /> <br /> Date Issued: <br />S) /2 7 t- 6 6 - 0-5/17 <br /> <br />/ II <br /> <br />Grout Inspection By/Dates: iZ <br /> <br />1 <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name (, , ,,,, -1 'Le_ FA Address ; ,,, : 6-6.,,,v-t-- ..i- FA#I e L__.-_PR# ,,_ ',) <br />FA PE WP Reviewed By ./, I Work Plan Date :L.., /'-:,, / -4- -,-, l' / <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Work Plan T33 5-13 f tel 3.1 I 3 -TiGAIi 22-7t6 L-ye Loti -1/,-) cr-061 -)K43 <br />Permit 23/,0 5. 3) 3 $1-3tx q 1 1 2.271 L -,e (a ii„,—, hi sy. 00113ci LI <br />Site Mitigation Well Permit Application EHD 29-01 6-23-2015