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RECEIVED <br />OCT 05 2016 <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: www.sicehd.com i6rENTAL <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION risElvicETLTH <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 517 West Fremont Street City/State/Zip Stockton, CA, 95203 Phone (209) 601-4169 <br /> <br />Cross Street N. Lincoln Street APN 137-214-10 <br /> <br />Property Owner* Guardino, Crawford CO - Dave Guardino <br /> <br />Phone (209) 601-4169 <br />Address 517 West Fremont Street City/State/Zip Stockton, CA, 95203 <br />C-57 Contractor Advanced GeoEnvironmental, Inc (AGE) <br />Address 837 Shaw Road <br />Consultant/Sub-Contractor AGE <br />Address 837 Shaw Road <br />License# 680227 Phone (800) 511-9300 <br />City/State/Zip Stockton, CA, 95215 <br />License# 680227 Phone (800) 511-9300 <br />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 NUMBER <br />MONITORING <br />El EXTRACTION (Vapor/Water) <br />El SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam, Ozonel <br />EZI OTHER 2 soil-vapor wells El <br />WELL/ SOIL BORING IDs V-1 and V-2 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 5.5' E3 BOLTED TRAFFIC BOX ID STOVE PIPE <br />DIA. OF BOREHOLE 3.0" U MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA NA <br />CASING THICKNESS 0.25" Tubing TYPE OF CASING: 0 STEEL D PVC 0 OTHER Teflon® tubing <br />CONDUCTOR CASING I=1 Yes 0 No Boring Dia: NA Casing Dia: NA Casing Depth: NA <br />GROUT SEAL DEPTH 3.5' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE U PIPE <br />GROUT SEAL PUMPED? El Yes D No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Potland Type I/II 5-6 gallons water per 94Ib <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <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 LI PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1 <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: See Soil-Vapor Investigation Work Plan dated 16 June 2016 (attached) <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />Sifh Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Project Geologist / AGE <br />Print Name Brian Millman Date 05 October 2016 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />DEPARTMENT USE ONLY <br />/72X/4 <br />Date Issued: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name FA Address FA# eN, 23 ) z PR# 0,5- lit 3 q 2/ <br />FA PE WP Reviewed By .,/Vp7 -,,•-01.-/ Work Plan Date <br />EK57 El C-57 Authorization for Other to Sign Permit 13./V-orker's Comp 0 Worker's Comp Waiver El Encroachment Permit El Access Agreement Erll'ad Agency Approval aml-R <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit Z901 3') $139x Z. A 279.- .2 I <DI7 CA27/ / $'12 oo 75-9 7 7 <br />ty ke k 29a -// $ 4/ / 7 2' 6 l'A/t/e se oo <br />EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />Signed