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)�Aat�BOG SHAHAN Environmeol Health Denar# en' L `' —COUNTY RECEIVED ` cp�tr Greatness grows h-. AUG 012017 SITE MITIGATION WELL & BORING PERMIT APPLIC N For Wells and Borings Used for Contaminant Investigations and Re N�T!! NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 17100 Murphy Parkway City/State/Zip Lathro ;'CA,95330 Phone 925-674-8400 Cross Street Harlan Road APN 198-120-09 Property Owner* Re Louise LLC,Et AL Phone 925-674-8400 Address 1200 Concord Avenel,Suite 200 City/State/Zip oncord,CA,94520 C-57 Contractor Advanced GeogRyironmental,Inc. License# 68 27 C57) Phone 209-467.1006 Address 837 Shaw Road City/State/Zi Stockton,CA,95215 Consultant/SubContractor All Well Abandonment License# 8 8359 Phone 916-363-9355 Address 3369 Fitzgerald Road Suite B City/State/ Ip Rancho Cordova,CA 95742 CONSTRUCTION WORK TO BE PERFORMED:Note: Offsite BoringsM/ells Re uire Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICAT NS ❑ MONITORING ❑ HOLLOW STEM BORING DE�TH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapwlWater) ❑ HAMMER/DRIVEN DIA.OF BOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THISS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CA G es ❑No Boring Ole: Casing Dia: Casing Depth: ❑ INJECTION(Air Swee,Omnel ❑ HAND AUGER GROUT SEAL DEPT 12 l TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATION rgand cement DESTRUCTION WORK TO BE PERFORMED: STRUC ON METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 1 one OVER-BOR DIAMETER of_inches to depth of feet WELL We W-1 ®PRESSURE G OUT To depth of 20 feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ❑PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface 9>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the ork will be done in accordance with S/a'n Joaquin�C/oJt(��qy�Qrdinance Codes and Standards,and all other applicable California laws. Signed UJ B CC'�1'[�iL ) Title/Company Geologis"GE Print NameWilliam Little Date O8/01/2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Site Information FA Name FA ddress FA# PR# FA PE P Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SCI FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVON:E# Permit $152x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-0147 Site Mitigation Well Permit Appliration