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Phone 209-948-0302 Job Address 655 - 639 West Clay Street City/State/Zip Stockton, CA, 95206 <br />Cross Street Harrison Street APN 147-071-0706 14170 7 it0 <br />License# 680227 Phone 209-467-1006 Consultant/Sub-Contractor Advanced GeoEnvironmental Inc. <br />City/State/Zip Stockton, CA, 95215 Address 837 Shaw Road <br />MW-30 <br />Print Name William Little Date 28 November 2016 <br />DEPARTMENT USE ONLY <br />Application Accepted By: -7-fee-e<ci <br />(v--29,, 3 5-2-3 <br />EHD 29-01 10-26-2015 <br />$'"/7 — 219 0.127c / 2 /5 / / ef S Aoo763 7 2_ <br />2 I <br />Site Mitigation Well Permit Application <br />RECE WED <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT DEC fl 1 2016 <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicsiRMASERVICES <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <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 />Phone 209-948-0302 <br />PO Box 6099 City/State/Zip Stockton, CA, 95206 <br />All Well Abandonment License# 848359 Phone -916-363-9355 <br />City/State/Zip Rancho Cordova, CA, 95742 <br />Property Owner* <br />Address <br />C-57 Contractor <br />Address 3369 Fit7geraldlinari <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />n( MONITORING <br />EXTRACTION (VaporlWater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Kir Sorge, Ozone( <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1 INCHOLLOW STEM BORING DEPTH 85 El BOLTED TRAFFIC BOX 0 STOVE PIPE <br /> 0 HAMMER/DRIVEN DIA. OF BOREHOLE 8-inch 0 MULTIPLE CASINGS 12 MULTI-LEVEL WELL CASING DIA <br />MUD ROTARY CASING THICKNESS 0.154-inch TYPE OF CASING: 0 STEEL M PVC 0 OTHER <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 9 No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH 0.5-70 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />OTHER: GROUT SEAL PUMPED? 0 Yes 111 No (Note: Maximum Freefall Depth is 30 Ft) <br /> GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs bag <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San pa uin y Ordinance Codes and Standards, and all other applicable California laws. <br />Signed 442 /IP Title/Company Senior Project Geologist/AGE <br />FA Name FA Address FA// 00 Z,3777 PR# 05 11 i 4 77 <br />FA PE WP Reviewed By ,/ _ <br />--"vx"e7 Work Plan Date 3i A-kic,c1 r Zet le v <br />01-57 0 C-57 Authorization for Other to Sign Permit 114orkers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement Er_ead Agency Approval &CFR <br />COMMENTS/CONDITIONS: 0...0.1-4,0.1 pa- otopro.ed LL:t• rt:- P lias , <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit -2',)0( .._:;/ :;-% $139x / /...3 - 019 Lta t. 1 2/5 /14 ,:)(yc,' -76J ( :3 <br />Knife River Corporation <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: L /F <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED Ej AUGERS LI HOSE 1:1 PIPE <br />COMMENTS: <br />1=I OVER-BORE <br />I] PRESSURE GROUT <br />Li EXPLOSIVES <br />LI MUSHROOM CAP <br />DIAMETER of inches to depth of feet <br />To depth of feet below surface <br />From to feet below surface <br />D 3 feet below surface or feet below surface if >3 feet <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY'(