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"QD y. • SAN JO QUIN COUNTY • <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> �q•. � Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s*clov.org/ehd <br /> �/FOR <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 /> Jeb Address 500 East Louise Avenue City/State/Zip Lathrop, 95330 Phone <br /> Cross street Harlan Road APN 198-120-08 <br /> Property Owner` RB Louise LLC, etal Phone 925-674-8400 <br /> Address 1200 Concord Avenue, Suite 200 Citylstate/zip Concord, CA 94520 <br /> C-57 Contractor AGE License# Phone 209-467-1006 <br /> Address 837 Shaw Road City/StatelZip Stockton,CA 95215 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/StatelZip <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 50 FEET ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERORIVEN DIA.OF BOREHOLE 3inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> SOIL VAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> SOIL BORING X PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes 91No acting Dia: Casing Dla: Casing Depth: <br /> ❑ INJECTION IPirsoam.,ozonel D HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 91 AUGERS [I HOSE 91PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes 91 No (Note:Maximum Fre Wl Depth is 30 Ft) <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS p ortlarlrl <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSUREGROUT To depth offeet 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: Soil Borings : GP-24 to GP-37 37.806791 -121.28879 <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> t� Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed W San Joaquin comfy Title/Company geologisVAGE <br /> Print Name William Little Date 09/15/15 <br /> ,t� _lJ DEPARTMENT USE ONLY <br /> Application Accepted By: /(/!� �rF/�/ Date Issued:�/�•� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Pennlit ❑Workers Comp ❑Workers Comp Waiver ❑E`ncroachmem Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: /hv1fl-1L T/CN2/' G /OelC 22�G /Y/' �/rr�ee jO'GV, P2 Mf "& ltr <br /> e:7'1/AVG <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 2905 313 $130 x 3 340— 1?1ST Nr) . q J5/s' Sk OD79203 <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />