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• 0 <br /> 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.siaov.org/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 /> Property ownera RB Louise LLC, etal <br /> Address 1200 Concord Avenue, Suite 200 CltylState2ip Concord, CA 94520Phone 925-674-8400 <br /> C-57 contractor All Well Abandonment License# 848359 Phone 916-363-9355 <br /> Address 3369 Fitzgerald Road Suite B cityistate/zip Rancho Cordova, CA 95742 <br /> Consultant/Sub-Contractor AGE License# Phone 209-467-1006 <br /> Address 837 Shaw Road City/StatelZlp Stockton,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Onsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORINGNU _E1' INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> X MONITORING ME a( HOLLOW STEM BORING DEPTH 2OFEET ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapxMater) ❑ HAMMERIDRNEN DIAOFSOREHOIE 8 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 91 No Boring Dix Casing Dia: Casing Depth: <br /> ❑ INJECTION Rem,owner ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 91 AUGERS ❑HOSE LI PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes &I No (Note:Maxenum Freelal Depth is 30 FI) <br /> WEWSOILBORINGIDs GROUT SPECIFICATIONS portland <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 Todepth of_feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From_lo_feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if 3 feet <br /> COMMENTS: 37.806791 -121.288790 <br /> I hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with <br /> wnSan J aqui ty Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed W� Ujci t_ Title/Company geologist/AGE <br /> Print Name William Little Date 09/15/15 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: i is Ni�11 c\,, !d\ Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: <br /> Facility/Site Information <br /> FA Name FA Address - FA# PR# <br /> FA PE I WP Reviewed By I Work Plan Dale <br /> ❑C-57 ❑C57 Autho cation forOlherto Syn Pernit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreemenl ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> X70/3I" <br /> Permit Zyc l �1' $130X 13Q <br /> EHD 29-016-23-2015 " ' I 1 Site Mitigation Well Permit Application <br />