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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: wwvv.sicehd.comVIRONMENTAL HEALTH a <br />SITE MITIGATION WELL & BORING PERMIT APPLI Onr <br />cAT-eIN <br />RMIT/SERVICES <br />--- <br />For Wells and Borings Used for Contaminant Investigations and Remediat: <br /> <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 />IRECIENED <br />JUN 1 5 2017 <br />Job Address CITY RIGHT-OF-WAY - HARRISON STREET City/State/Zip STOCKTON Phone 209-937-8349 <br /> <br />Cross Street WEST CLAY ST. & SOUTH HARRISON STREET <br />APN <br />WEST CLAY PROPERTY (KRC) Phone 209-948-0302 <br /> <br />639W. CLAY ST. <br />City/State/Zip STOCKTON, CA 95209 <br />C-57 Contractor GULF SHORE EXPLORATION License# 848359 Phone <br />City/State/Zip RANCHO CORDOVA CA 95742 <br />Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL INC. License# <br /> 680227 Phone 209-467-1006 <br />Property Owner* <br />Address <br />Address 3383 FITZGERALD RD. <br />916-939-4117 <br />Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />MONITORING IM HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />In SOIL BORING 3 0 PUSH POINT (GP/ CPT) <br />INJECTION (Air Sparae. Ozone) El HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs B-19, B-20, B-21 <br />NA <br />CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER NA <br />CONDUCTOR CASING 0 Yes 0 No Bonng Dia: NA Casing Dia: NA Casing Depth: <br />GROUT SEAL DEPTH 90 feet TREMIE TYPE TO BE USED: n AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? El Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS PORTLAND TYPE II <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 90 feet 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 8-INCH 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br />NA <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />OVER-BORE DIAMETER of inches to depth of feet <br /> 0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES <br />D MUSHROOM CAP <br />From to feet below surface <br />0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />see RWOCB-Approve3d Work Plan, dated 08/31/2016 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Signed <br />San J aquin County Ordinance Codes and Standards, and all other applicable California laws. <br />/4tr(4i . Title/Company PROJECT MANAGER <br />Print Name TIMOT . CUELLAR Date 06/14/2017 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: Yi i Cj L_ <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: <br />1/ 72 WV , 7 ' <br />FA Name Vf ( i- I i FA Address to-11 `-'`) CI S•t- FA# e 0 2_ ...i ), ) 5-- PR# <br />FA PE (.)- c I L-- ‘_, WP Reviewed By L. -.-- Work Plan Date .._':i7- ( 3 1 7.47 <br />o 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 />Permit 2A, 0 ec -313 $139x 3 $ LI i 1 22a 2,5„ L.-ix Y 11-i /(-1 5 KO 01-1 8 Li 2, <br />t-1 -1 •zci 03 çT31 313 <br /> <br />t L111 2-242-G L -Y e_ oo <br />EHD 29-01 10-26-2015 <br /> <br />Site Mitigation Well Permit Application