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ip <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3147 Fax.(209)468-3433 Web:wWW.sinov.ora/ehd <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 500 East Louise Avenue City/State/Zip Lathrop, 95330 Phone <br /> Cross Street Harlan Road APN 198-120-08 <br /> Propertyownee RB Louise LLC, etal Phone 925-674-8400 <br /> Address 1200 Concord Avenue, Suite 200 city/staterzip Concord, CA 94520 <br /> C-57 Contractor All Well Abandonment License# 848359 Phone 916-363-9355 <br /> Address 3369 Fitzgerald Road Suite B city/state/zip Rancho Cordova, CA 95742 <br /> Consultant/Sub-Contractor AGE License# Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zlp Stockton,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringslWelis Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER IN TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM BORING DEPTH 20FEET 91 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VoWlWater) ❑ NAMMERIDRIVEN DIA OF BOREHOLE flinches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DW <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:C3 STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes 91No Boring Dla: Casing Dia:_Casing DepN: <br /> ❑ INJECTION(4 emme.omoel ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: 93 AUGERS ❑HOSE E3 PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? El Yes ®No (Nola:Maximum Freefal Depth is 30 Fit <br /> WEWSOILBORINGIDs GROUT SPECIFICATIONS pprtland <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> If WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of_feet <br /> WELL IDs ❑PRESSUREGROUT To depth of_feel below surface <br /> GROUT SPECIFICATIONS [I 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 /> COMMENTS: 37.806791 -121.288790 <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> LA) <br /> i, A Sae Kaqul" " ty Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed XD.IA.-►.•.:fA.e_►U Tit(e/company 9eologisUAGE <br /> Print Name William Little Dale 09/15/15 <br /> \ DEPARTMENT USE ONLY <br /> U / <br /> Application Accepted By: � e1 Hen dLltSO✓1 Date Issued: <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Dale <br /> ❑C-57 ❑CS7AuthorizaWnfor0therlo Sign Perms ❑Wodrers Comp ❑Workees Comp Waiver ❑Ercsoachment Permil ❑Across Agreement ❑Lead Agency Approval ❑MFR <br /> COM M E NTSICONDITIONS: <br /> SR TYPE PE SC I FEE INFO JAMIT REmrrrEi)l CHECK#I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# <br /> Work Plan 27o l391 <br /> Permit 2-90( 313 $130 X S 00733' <br /> EHD 29-016-23-2015 " ' f I Site Mitigation Well Pemiil Application <br />