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r?EcEIVE® <br /> ,aP` t•,so SAN JOAQUIN COUNTY AUG ?5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT 2016 <br /> a�_ ENV1R <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 CN+VENTA1 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.smcehd.com <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 14101 S Manthey Rd ✓ City/StaterZip Lathrop, CA 95330 Phone <br /> Cross Street De Lima Road APN 191-220-14 <br /> PropertyOwner* DoE Reis Ranch Inc. ✓ Phone (209)466-7915 <br /> Address 7000 S Inland Drive ✓ City/State/Lip Stockton CA 95206 <br /> C-57 Contractor Confluence Environmental, Inc. License# 913194 Phone (949)716-4971 <br /> Address 3308 EI Camino Ave.Suite 300#148 City/State/Zip Sacramento C4,95821 <br /> Consultant/Sub-Contractor HydroFocus, Inc. License# Phone (530)759-2484 <br /> Address 2827 Spafford Street City/State/Zip Davis CA 956 8 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BO ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMEWDRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS 13 MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: El SI EEL [I PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING [I Yes (:1 No Boring Dia: Casing Dia: Casing Depth. <br /> ❑ INJECTION IAh Soarae.Ozanel ❑ HAND AUGER GROUT SEAL DEPTH TREMIETYPETOBE USED: ❑AUGERS CHOSE ❑PIPE <br /> [I OTHER El OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:fCHECIKLL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 0 OVER-BORE DIAMETER of8!' inches to depth of 7 _feet <br /> WELL IDs CLSP-2 ❑PRESSURE GROUT To depth of feel below surface <br /> GROUT SPECIFICATIONS neat Cement ❑EXPLOSIVES From_b_feet below surface <br /> TREMIE TYPE TO BE USED N AUGERS [:]HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> 1 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 Megan Kerns Title/Company President/Confluence Environmental <br /> Print Name Date <br /> 8193/201 R <br /> �,r// <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Joe/ Date Issued: /�/d/ZL <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: O417 .14 <br /> Facility/Site Information <br /> FA Name FA Address FA# PR 12 <br /> FA PE WP Reviewed By N C f e•� Work Plan Date 1 2 5 14 <br /> G57 ❑C-57 Authorizagon for Other to Sign Permit orkers Comp ❑Worker's Comp Waiver ❑Encroachment Permit A ess Agreement ad Agency Approval FR <br /> COMMENTS/CONDITIONS: Q ,* ux,*1,c r r(a d Cv%ACvCt I eeu-t -1 Gort4 5° H Aek,be. lei uJ'1 ppt f{f aeN CatA4.ihl- <br /> ^J <br /> SR TYPE PE SC .k FEE INFO ABMT REMITTED CHECK# RRE'CVV''Df IS DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 2903 5Z J1 /1/f/ /- �/ r�'//s`� CAI Z /1 SW007".99 <br /> Permit 29v2 313 $1agX I $/35 S -Ys CA/r/I' gZ5 //P SDo76600 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />