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oPa"•IN• SAN JOAQUIN COUNTY 0 RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT AUG 25 2016 <br /> 11IE 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> �'•• :p Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.smcehd.com ENVIRONMENTAL <br /> ArFO � <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATI( 'LTH, DEPARTMENT <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 12965 S Manthev Road City/StatrlCip Lathrop.CA 95330 Phone <br /> Cross Street De Lima Road APN 191-220-05 -- <br /> Property Owner* Alice J.Widmer Z Phone (209)915-4245 <br /> Address 12375 Droge Rd ✓ Clty/statelzip Escalon CA 9E 320 <br /> G-57 Contractor Confluence Environmental, Inc. License# 913194 Phone (949)716-4971 <br /> Address 3308 EI Camino Ave. Suite 300#148 City/State![ip Sacramento,CA 95821 <br /> Consultant(Sub-Contractor Hydro Focus, Inc. License# Phone (530)759-2484 <br /> Address 2827 Spafford Street City/State/Zip Davis. CA 9561118 <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 BOX El STOVEPIPE <br /> ❑ EXTRACTION(vapor/water) ❑ HAMMERMRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS I I MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: D S1 EEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING El Yes 0N Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION INraoeme.omnel ❑ HAND AUGER GROUT SEAL DEPTH TRENT TYPE TO BE USED: ❑AUGERS El HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELT SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: cHEck LL THAT APPLY <br /> #WELLS TO BE DESTROYED 1 0 OVER-BORE DIAMETER of 8 inches to depth of 17 feet <br /> WELL IDs CLSP-10 [-1 PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From In_feet below surface <br /> TREMIE TYPE TO BE USED ■AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below urfaceor feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San q�o/g� ,, <br /> qu n County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed X L/V IVU Title/Company President/Confluence Environmental <br /> Print Name Megan K s Date 8/23/2016 <br /> �/' DEPARTMENT USE ONLY <br /> Application Accepted By: .,�aG/¢/.� �sv? Date Issued <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# I 002_3.Z1 PR# aAe1e5 -Fr <br /> FA PE WP R iewed By I WpelWork Plan Date <br /> 557 ❑C-57 Authorization for Other to Sign Permit orkers Comp ❑Workees Comp Waiver ❑Encroachment Permit ess Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CON D ITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 29GZ 3yj $13,Qx ;1i"I3y 8y4 CNI ' 82S /� f/?007600� <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />