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SANJOAQUIN Environmental Health Department <br /> —COUNTY <br /> (, Greatness grows here. <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 /> 48 Hours Advance Notice Required For All Inspections <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 Stewart Road City/StatoIZip Lathrop/ CA/ 95330 Phone <br /> Cross Street B Paradise Road APN 213-61-005 <br /> Property Owner' River Tslands Development LLC Phone (209)879-7900 <br /> Address 73 Stewart Rd City/StatelZip Lathrop/ CA/ 95330 <br /> C-57 Contractor Geo Rx Llcense# 954267 Phone (866) 942-2315 <br /> Address 1016 Lincoln Blvd City/State/Zip San Francisco, CA, 94129 <br /> Consultantsub-Contractor BNGEO, Inc. Llcense# Phone (925)786-7895 <br /> Address 17278 Golden Valley Parkway City/State/Zip Lathrop/ CA/ 95330 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUEIORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX [I STOVEPIPE <br /> ❑ EXTRACTION(VaporMater) 0 HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: [I STEEL [I PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring De: Casing Dix. Casing Depth: <br /> ❑ INJECTION(asoxae.Ozonel ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefa0 Depth Is 30 Ft) <br /> WELUSOIL BORING IUs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED t feetx R <br /> WELL IDs MwRI 1-1 PRESSURE GROUT To depth of 20 feet belay surface <br /> GROUT SPECIFICATIONS neat cement El EXPLOSIVES From_t0_feetbelowsudace <br /> TREMIE TYPE TO BE USED [IAUGERS ElHOSE ®PIPE ElMUSHROOM CAP ❑3 feel below surface a feet below surface if>3 feet <br /> COMMENTS: <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed Title/Company Project GeologisUENGEO,INC. <br /> Print Name CodYJohnson Date <br /> tatvzozs. <br /> r.�) DEPARTMENT USE ONLY <br /> Application Accepted By: Otp.cG /V Date Issued: IO I�3 /ZO Z3 <br /> Grout Inspection By/Dale <br /> Destruction Inspection By/Dates: ,f1DVL1,t <br /> Facilit /Site Information <br /> FA Name {� d2r +S��npl,s FAAddress ar„�. d- � s�ls� FA# 00226 q PR# ofj3rl' <br /> FA PE 'L Q WP Reviewed By J w Work Plan Date to — Z, <br /> ❑C57 C-57 Author'izalim for Other to Sign Permit ❑Workers Comp ❑Wakens GompWa1I ❑ Encroachment Pemlil ❑Across Agreement ad AgelwyAppmval FR <br /> COMMENTS/C NDITIONS: <br /> WP TYPE (nAPE SC FEE INFO AMT REMITTED C/HEE�CK# REc%rD BY yT DATE WELL <br /> WELL PERMIT# INVOICE# <br /> Permit /L-60 8 (U.< I p-IG'//fli DO s� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 2 4�8-3�'�gf'I F 209 464-013 www.s ceA .Com <br /> EHD 29-0108-01-17 n1 fT I vrO (mob IT�r Z Site MWgaion Well Permit Application <br />