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SAN JOAQUIN Environmental Health Department —COUNTY .-?Otness grows her SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 615 East Main Street City/State/Zip Stockton,CA 95202 Phone 209-937-8893 Cross Street North American Street APN 149-180-070 Property Owner* Creative Education Support Ong LLC Phone N/A Address 4719 Quail Lakes Drive,Suite G 237 City/State/Zip Stockton,CA,95207 C-57 Contractor AdvancedGeo,lnc. License# 1063765 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 95216 ConsultanVSub-ContractorAdvancedGeo,lne. License# 1063765 Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA 96215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offstte BodngsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 1 ® HOLLOW STEM BORING DEPTH 40 ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: [I STEEL ®PVC ❑OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION INr Soave.Omne1 ❑ HAND AUGER GROUT SEAL DEPTH 16' TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Nate:Maximum Fre lfall Depth is 30 Ft) WELL/SOIL BORING IDs TBD GROAT SPECIRCATIONS Portland Cement 6 gallons per 94 lbs sack DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feet WELL IDS ❑PRESSUREGROUT To depth of feet below surface GROUT SPECIFICATIONS [I 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 I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company SENIOR GEOLOGIST/A.G.I. Print Name Daniel Villanueva Date �- DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑G-57 ❑C57 Authanzation for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Appmval ❑MFR COMMENTSICONDITIONS: WP TYPE I PE SC I FEE INFO AMT REMITTED CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2MI OMl-17 Site Mitigation Well Permit Application