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ip <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AUG 25 2016 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sicehd.c0rn-IGAITH DE^/`,�T1r9ENT <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 16400 Cohen Road(River Islands) City/State/Zip Lathrop, CA 95330 Phone <br /> Cross Street Stewart Road1 APN 213-230-05 <br /> Property Owner* Califia LLC Rrver 1-s Ic"ds LC.0 ✓4/ Phone (209)879-7900 <br /> Address 73 Stewart Road 7999 O4 k Od 54 tlo0 City/State/Zip Lathro-CA�9 30 y-Sy <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 C 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 BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMEPuORIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION IAMno .Omnel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefol Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLYI <br /> #WELLS TO BE DESTROYED 1 ■OVER-BORE ✓ DIAMETER of 811 inches to depth of 16 feet <br /> WELL IDs MWR-20 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From t _feet below surface <br /> TREMIE TYPE TO BE USED 0 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or 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 494uIn County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed IV-C� Title/Company President/Confluence Environmental <br /> Print Name Megan KeQs Date 8/23/2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: /ti5Ory Date Issued <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: }' <br /> Facili /Site Information <br /> FA Name FA Address 00 2. P/� FA# 00 Z 32/ PR# 0 S-'/0588 <br /> FA PE WP Reviewed By " /SoH Wodc Plan Date I <br /> 57 ❑C-57 Authorization for Other to Sign Permit orkees Comp ❑Workets Comp Waiver ❑Encroachment Permit 2c�ess Agreement ❑Lead Agency Approval 43-WFR <br /> COMMENTS✓CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE#.. <br /> Work Plan ccA�- '�tt'� o <br /> Permit Z202— 3l3 $130x ( .� 39 O-1/� CAW(-e 0 2,51L 51Rov76002 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />