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SAN JOAQUIN COUNTY �� <br /> ENVIRONMENTAL HEALTH DEPARTMENT F qaR?� `'' <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 p RD{%gfF�,l <br /> � � Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com �tfi"In �H <br /> v`b'R 0Nj <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <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 375 WEST HAZELTON AVENUE Clty/StatelZip STOCKTON. CA 95203 Phone 209-943-7777 <br /> Cross Street HAZELTON AVE. &S. LINCOLN ST APN 147-110-12 <br /> Property Owner* EGER PROPERTIES C/O JO EGER Phone 209-943-7777 <br /> Address 201 N. FRANKLIN ST., SUITE 300 City/State/Zlp TAMPA„ FL 33602 <br /> C-57 Contractor GULF SHORE EXPLORATION License# 964224 <br /> Phone 916-839-4117 <br /> Address 3383 FITZGERALD RD/ Clty/StatelZip RANCHO CORDOVA, CA 95742 <br /> Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL INC. License# 680227 Phone 209-467-1006 <br /> Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 23 MONITORING 1 9 HOLLOW STEM BORING DEPTH IJ BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/N/ater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCHED.40 TYPE OF CASING: ❑STEEL I9PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes ®No Boding Dia: NA Casing Dia: NA Casing Depth: NA <br /> ❑ INJECTION fAr Some.ozonel ❑ HAND AUGER GROUT SEAL DEPTH 115' TREMIE TYPE TO BE USED: MAUGERS El HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDS MW-21 GROUT SPECIFICATIONS PORTLAND TYPE II <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE. DIAMETER of_inches to depth of_feel <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES - From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: S£C WQcl3^ .*,fprQ tt.0 WQ AN pActO 03-" - -L01 7 <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> pP � � San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> �/ <br /> Signed ;yN tll.7 Title/Company PROJECT MANAGER/ADVANCED GEOENVIRONMENTAL <br /> Print Name TIMOTHY J.CUELLAR Dale 0 412 0/2 0 1 7 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: �1'I ~ - Date Issued: 7 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facllit ISlte Information <br /> FA Name S ieflA / ,L, �a / FA Address 37,5 �. %d �Id,� FA# C�p � 7� O,F. PR# (,� LiG `1s' <br /> FA PE .- Zi' 6 '( WP Reviewed By / Work Plan Date j -:2 <br /> Ia•'C-57 ❑C-57 Authorization for Other to Sign Permit 2TWorkersComp ❑Worker's Comp Waiver ❑EncmachmenlPermil ❑Aaess Agreement EfLead Agency Approval MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC I FEE INFO jAgIMT RENin-TED1 CHECK# I RECV•D BY DATE SERVICE REQUEST# INVOICE# <br /> Permit 2-`'C) 31 ' $139 x Gl�l .• S <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />