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SAN JOAQUINartment Environmental Health ® ep „ r SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209 ) 9534697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct andlor install the work described . This application is made in compliance with San Joaquin County Development Title, Chapter 9- 1115. 3 , and the San Joaquin County Well Standards, Job Address 715 North Hunter Street City/State/Zip Stockton , CA Phone 209-483 -9993 Cross Street Park Street APN 139-054-090-000 Property Owner* Dennis Erardi phone 209-4B3-9993 Address PO Box 691000 City/State/Zip Stockton , CA 95269 AdvancedGeo Inc. C-57 Contractor License# 1063765 Phone 209 467- 1006 Address 837 Shaw Road Ci /State/Zi Stockton , California 95215 tY P Consultant/Sub-Contractor Slagle Drilling Corperation License# 1046151 Phone 916-363-9355 Address 11345 Trade Center Drive City/State/Zip Rancho Cordova , CA 95742 CONSTRUCTION WORK TO BE PERFORMED *Note: Offsite BoringsfWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULT6LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS ❑ HOSE El PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED two (2 ) ❑ OVER-BORE DIAMETER of 4 8 inches to depth of 40 feet WELL IDs MW4 & MW-9 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland type ll cement to surface grade ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS : Both MW4 & MW-9 will be over-drilled tQ 40 ifeet below surface grade. - her by i rtify that I am authorized to complete this application and that the work will be done in accordance with � San-J"6aquin County Ordinance Codes and Standards, and all other applicable California laws . Signed Title/Company Senior Geologist, AdvancedGeo , Inc . Print Name Daniel Villanueva Date May 04 2022 DEPARTMENT USE ONLY v p Application Accepted By: Date Issued : Grout Inspection By/Dates : gel Destruction Inspection By/Dates : . Facili /Site Information FA Namei ER 1:) !N / : l' I I A:;� 1 FA AddressFA# ® 2 p v FA PE WP Reviewed By Wont Plan Date ❑ C-57 E -Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver xhment Permit ❑ Access Agreement El Plead Agency Approval FR COMMENTSICONDITIONS: WP TYPE PE SC FEE INFO AMT REMIT 'T/E'D CHHECK#( RECVD yBY DATE WELLPIERMIIT# INVOICE# Permit $ 152 x I � � `� Cc � 3/1 172 , W POO 1+530 Y �'oryt,.f `o Avenue 1868 E . Hazelton Avee Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 1 www . sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application