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.r '-fJI 0Ul14 �p $AN JOAQU IN Environmental Health Department —COUNTY— .:.. Greatness grows here, 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) 953-7697 For INSPECTIONS Application Is hereby made to San Joaquin County for a permit to construct and/or 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 330 West Harding Way City/State/Zip Stockton, CA 95204 Phone 408-660-7473 Cross Street Van Buren Street APN 137-080-010-000 Property Owner* Atul Balra Phone 408-660-7473 Address 91 Los Altos Drive City/State/Zip Hollister, CA 95023 C-57 Contractor AdvancedGeo, Inc. License# 1063765 Phone 800-511-9300 Address 837 Shaw Road CltylStatelZip Stockton, CA 95215 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone 800-511-9300 Address 837 Shaw Road CltylStatelZip Stockton, CA 95215 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BodngsMells Require Access Agreements or Encroachment Permits TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6.5 f1.bsg ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.0 inches ❑MULTIPLE CASINGS[I MULTI.LEVELWELL CASING DIA ® SOILVAPORPROBE 4 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER ❑ SOILBORING IN PUSH POINT(GP/GPI) CONWCTORCASING [I Yes [I No Boring Dia: Casing Dia: CNIng Depth: ❑ INJECTION(AFsome.Onel IN HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEWSOILBORINGIDs SV5SV8 GROUT SPECIFICATIONS Each b rirgWl be feed vAh cemenlgrotto su ace grade. M .,pQ� pp d C�(f I LY°.lL DESTRUCTION WORK TO BE PERFORMED: DESTRUOTI N MEYHOD: (CHECK AutTMHAT APPLY)S VP If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑ PRESSUREGROUT Todepthof feetbelowsudaoe GROUT SPECIFICATIONS [I EXPLOSIVES From to—feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP ❑3 feet below surface or feel balm surface if>3 feel COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San J Title/Company oaquin County Ordinance Codes and Standards,and all other applicable California laws. � Senior Staff Scientist,AdvancedGeo, Inc. Signed ��v11I .y�/r, Print Name Jasleen Singh Date 0 912 212 02 3 DEPARTMENT USE ONLY Application Accepted By: Dale Issued: Grout Inspection BylDates: Destruction Inspection By/Dales: �/ Facilil /Site Information FA Name e-5 FA Address "'Q 4. in FA# 3 PR# Q FA PE WP Reviewed By Work Plan Date firzD �� C-57 ❑C-57Authaixadon for Olherto Sign Permit ❑Workers Comp ❑Workers Comp Walver /❑Encroachmenl Pe '1 ❑Access Agreement ' ead Agency Approval KMFR COM NTSICONDITIONS:,�7 V q -`' fo\,t' - Cd,_ WP TYPE PE I SC I FEE INFO JAMTRE111i CHECK# RECVV'ID'/B IY DATE in`WELL PERMIT# INVOICE# Permit [ 131511 � ZK ((��qC '`.1��r'l��/ �i� V r� o0 1868 E. Hazelton Avenue I Stockton, California 95209 Tg 09 46"420 1 F 209 464 �w w s ce .com EHD 29-01 04-04-07 Site Migga6on Well Permit Applira5on