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SA N J OAQ U I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <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 /> 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 /> Job Address COS ROW in front of 601 East Main Street City/State/Zip Stockton,CA 95202 Phone 209-937-8893 <br /> Cross Street North American Street APN NIA <br /> Property Owner' City of Stockton Phone 510-756-7095 <br /> Address 345 North El Dorado Street City/State/Zip Stockton,CA 96202 <br /> C-57 Contractor AdvancedGeo,lnc. License# 1063765 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA 95215 <br /> Consultant/Sub-ContractorAdvancedGeo,lne. License# 1063765 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ® HOLLOW STEM BORING DEPTH 30 and 75 ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ KAMMERIDRIVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> IM SOIL BORING 2 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soame,ozone) ❑ HAND AUGER GROUT SEAL DEPTH 30 and 75 TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ®PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELLI SOIL BORING IDs TBD GROUT SPECIFICATIONS Portland Cement 6 gallons per 941bs sack <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CIHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <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 feet below surface or feet below surface if>3 feet <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed_ Title/Company SENIOR GEOLOGISTIA.G.I. <br /> Print Name Daniel Villanueva Date -Z-a ir <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By FW,)rk Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTSICON DITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01.17 Site Mitigation well Permit Application <br />