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• • jREC'EIVED ulf+ SAN JOAQUIN COUNTY MAY i ' ENVIRONMENTAL HEALTH DEPARTMENT 2 , 2017 1868 Hazelton Avenue, Stockton, CA 95205-6232 E PEON&fEly%AL H cils••• ,r Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:jnn .sicehd.com RMIr�S�RWCE� SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 16888 McKinley Avenue citylstate/zip Lathrop CA 95330 Phone 209-858-3384 Cross street F T ouise Avemre APN loll:-160-9F. Property owner* Superstore Indstries Inc. Phone 209-858-3384 Address 16888 McKinley Avenue Liense#icLathrop CA 95330 C-5T contractor Krazan &Associates Inc. ense# 499908 Phone 559-34R-2200 4 Address X115 Wrst Dakota Avenue City/State/Zlp Clovis.CA 93612 Consultant/sub-contractor Krazan &Associates. Inc. License# 5027 Phone 559-348-2200 1• citylstatelzip Clovis, CA 93612 ...< <y=�.r�,. Address >^ta Avenue CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ® HOLLOW STEM BORING DEPTH ❑MULTIPLEED TRAFFICSIN BOX [3 STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE NG: 0S❑MULTI-LEVEL WELL CASING DIA 91 SOILVAPOR PROBE 4 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER M SOILBORING 27 E3 PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes [I No Bodng Dia: Casing Dia: Calling Depth: [I INJECTION I45eozorar ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE [3 PIPE ❑ OTHER ® OTHER:Si1]Oli 1dSterT1GR0UT SEAL PUMPED? ❑Yes ❑No�(Note',Maximum Freetall Depth Is 30 Ft) WELD SOIL BORING IDs CR1 ^ SB27 GROUT SPECIFICATIONS cetnenigrout cv14^ SV4 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [:]OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs ❑PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below sudace or feet belay surface if�3 feet COMMENTS: ^* " I hereby certify that 1 am authorized#bcomplete this application and that thework will bedone in accordance with z/�� r San.Joaqui r Cou)tp.Ordinance Codes and Standards,and all other.applicable California laws. ' Title/Company i-n�r torr Mar)ager/Krayan & ACsociatec Inc Signed Print Name Michael Bowes _Date Mgy 25 2017 DEPARTMENT USE ONLY ) Application Accepted By: Date Issued: Grout Inspection By/Dates: ('1IA4 in a—,— `1 7 —613 Destruction Inspection By/Dates: Facility/Sit)Information FA Name j wV.1.lFo r �.rAvalrltS FA Address %WK14% rkrv "^Vj ��. FA# l7()'Z�(b fib' PR# OS`I I�IS�I FA PE a.C1 gD WP Reviewed By L�x Work Plan Dale si3q 1-1 ❑C-57 ❑C-57 Aulhonzation for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agerwy ApWoval ❑MFR \ COMMENTSICON DITIONS: SR TYPE I I SC FEE INFO AMT REMITTED CHECK# RECV'D.BY DATE SERVICE REQUEST# INVOICE# Ferrnit -1.-Axi 13 S139 x 3 `-tV'1 •20$''' L.- 7( � l y. xr.1 P 2-403 �z3 139 i 3 Hyl 1 Z° )`1 c blllt l S(t(7i3"l�� L2 EHD 29-01 10-26-2015 Site Mitigation Well Permit Application