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oP4 ly o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N < <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> �dt/Fsa�P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wwwAc-lov.orcl/ehid <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 fora 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 Owner* RB Louise LLC, etal Phone 925-674-8400 <br /> Address 1200 Concord Avenue, Suite 200 city/State/Zip Concord, CA 94520 <br /> C-57Contractor AGE License# Phone 209-467-1006 <br /> Address 837 Shaw Road city/state/zip Stockton,CA 95215 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 50FEET ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ RAMMERIDRIVEN DIA.OF BOREHOLE 3 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> IIFT SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El EIOTHER <br /> X�Y SOIL BORING PUSH POINT(GPI CPT) CONDUCTORCASING [I Yes 91No Boring Dia: Casing Dia:Casing Depth: <br /> ❑ INJECTION(Aireoxue.Qoo.) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE 91PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Fwfall Depth is 30 FQ <br /> WELL]SOIL BORING IDs GROUT SPECIFICATIONS p ortlanr9 <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 ❑PRESSURE GROUT To depth of_feet 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 feel <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 /> ' INS (� San Joaquin ounty Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed W J"�& Title/Company geolO9lsVAGE <br /> Print Name <br /> William Little Date 09/15/15 <br /> ,�tt// _/ DEPARTMENT USE ONLY J <br /> Application Accepted By: /!/t�C/ /�/�6<F/P/ �( Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By I Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Woftrs Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: /hvSf(/JG `r4'eot B lo,je of rifer rJ°rCJ�a cl�,da '+�/�✓/j 4-v'"�/'r jW`Y <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 2905 30 $130x <br /> X007.9903 <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />