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SAN JOAQUIN Environmental Health Department <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 /> lours Adv . Aice Requirec, ;�r All Insp, <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 17100 Murphy Parkway City/State/Zip Lathrop,CA,95330 Phone 925.674.8400 <br /> Cross Street Harlan Road APN 198.120-09 <br /> Property Owner* RB Louise LLC,Et Ai. Phone 925-674-8400 <br /> Address 1200 Concord Avenue,Suite 200 CitylState/Zip Concord,CA,94520 <br /> C-57 Contractor Advanced GeoEnvlronmental,Inc. License# 680227(C57) Phone 209.467.1006 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA,95215 <br /> Consultant/SubContractor All Well Abandonment License# 848359 Phone 916-363.9355 <br /> Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova,CA 95742 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERrIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ONO Bodng Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION IAF Spens.ozowl ❑ HAND AUGER GROUT SEAL DEPTH 12 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nate:Maximum Freefall Depth Is 30 Fl) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY? <br /> #WELLS TO BE DESTROYED 1(one) ®OVER-BORE DIAMETER of TWO inches to depth of 20 feel <br /> WELL IDs W-1 ❑PRESSUREGROUT To depth of—feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED W AUGERS Q HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS:Well Destruction <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> �i 1 Joaquin oun y Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed �'J _ ) Title/Company Geologist/AGE _ <br /> Print Name W I Iliam Little Date 0811412017 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: '__ <br /> Grout Inspection By/Dates: 34 <br /> Destruction Inspection By/Dates: <br /> FacIB /Site Information <br /> FA Name '-bt FA Address (Y/�,.Q FA# ,,r I PR# <br /> FA PE � �! WP Reviewed By L J vWoorrk Plan Date <br /> 57 ❑G57A0odzddon1or Otherto Sign PemI1 6TWorkersComp ❑Workefs Comp Waiver ❑Encroachment Penia ❑Access Agreement 06adAgency Approval MFR <br /> COMMENTS/CONDITIONS: N pie„ 6D re ICS -Nrv'L �q,,,v,(J o✓ .sem <br /> WP TYPE PE I SC FEE INFO JANIT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# <br /> Permit1$152x 1 �Sz y36.0 Ly Jj ��o0s~ltS <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-0108-01-17 She Mitigation Well Permit Application <br />