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SAN JOAQUIN <br />—COUNTY <br /> Environmental Health Depo2N <br />P6-1:4fe40- <br />fl G ,Pptripcs owc <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION 7-4516-/i,10/16.610.6, <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <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 />CITY RIGHT-OF-WAY <br />Job Address 2154 S. EL DORARDO STREET <br />Cross Street <br /> 8th Street & San Joaquin Street <br />Property Owner* City Of Stockton <br />Address 425 N. EL DORADO STREET <br />C-57 Contractor GULF SHORE EXPLORATION <br />Address 3383 FITZGERALD ROAD <br />Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL, INC. <br />Address 837 SHAW ROAD <br />City/State/Zip <br />APN R.O.W. <br />STOCKTON/CA/95206 Phone <br />Phone <br />Phone <br />Phone <br />209-467-1006 <br />209-937-8444 <br />City/State/Zip <br />License# <br />STOCKTON/CA/95202 <br />916-939-4117 964224 <br />City/State/Zip <br />License# <br />RANCHO CORDOVA/CA/95742 <br />209-467-1006 680227 <br />City/State/Zip STOCKTON/CA/95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />NUMBER INSTALLATION TYPE <br />3 El HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 1:1 HAND AUGER <br /> 0 OTHER: <br />MW-11, MW-12, MW-13 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 100 FEET <br />DIA. OF BOREHOLE 8-INCH <br />CASING THICKNESS SCH. 40 <br />CONDUCTOR CASING 0 Yes Ill No <br />GROUT SEAL DEPTH 83 FEET BSG <br />GROUT SEAL PUMPED? El Yes 0 No <br />GROUT SPECIFICATIONS <br />El BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 13 PVC 0 OTHER <br />TREMIE TYPE TO BE USED: IA AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />PORTALND TYPE II <br />TYPE OF WELL/BORING <br />3 MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Alr Searle. Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br />Boring Dia: 8-INCH 2-INCH Casing Dia: Casing Depth 100 FEET <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br /> <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />ID OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />Cl MUSHROOM CAP CI 3 feet below surface or feet below surface if >3 feet <br /> <br />GROUT SPECIFICATIONS <br /> <br />TREMIE TYPE TO BE USED AUGERS El HOSE El PIPE <br />COMMENTS: SEE RWQCB APPROVED WORK PLAN DATED 25 OCTOBER 2016 <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 uin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed <br />ct- <br />Title/Company PROJECT MANAGER/A.G.E. <br />Print Name TIMOT J. CUELLAR Date 10/19/2017 <br />Application Accepted By: <br />Grout Inspection By/Dates: L. it 1 So lii (8\w <br />DEP6RTMENT USE ONLY <br />Date Issued: t ii <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name ‘fir.As‘V A 17-44 4'i-0)K; FA Address 2-4S'i S. /..--i 'ittl S'i- FA# Do 2_3 -Is- I PR# Opii Li 3-.7 <br />FA PE PE ,.)-Ci (5-WP Reviewed By L -->C Work Plan Date 1 j, /25- /7--01?-; 6 <br />0 C-57 EKC#-57 Authorizakon for Other to Sign Permit 614(orkees Comp 0 Worker's Comp Waiver arrcroachment Permit 0 Access Agreement leead Agency Approval FR )0 <br />COMMENTS/CONDITIONS: -4?4,_.i,,.....vt <br />e.cidl..kvb.,'-9"A r.8., "AAA <br />U.) A'\ *i'e.10,1, <br />?e,ek-ci.„,..N3 tr..,tp :I-Q 1,-...• is, \-9-r v•iCln (-1-4-Vt," • `'',.., t 6: , r • 7 <br />,G-y-trjk enmsry 6{, (NJ-v.., kv-L4-0 WeAit 4. sv , 'WI_ 6,4t4 "." Av 44-c *T- <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit alci.t.)1 )i 3 $152x 3 ,i, (4,51„ 23.YA i I._ -.)4 1'I 01 h i -%A.) £ 0 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 20-01 08-01-17 Site Mitigation Well Permit Application <br />v 52," A 3 "Vil. 233i L.- )( is• I 5g_00-te 3 t(0