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40 46 <br /> N J U A Q U 1 N 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 /> 48 Hours Advance Notice Required For All Inspections <br /> Appiicalton is hereby made to San Joaquin Cointy for a permit to construct and cr instill the work described <br /> This application is made in compliance with San.Joaquin County Developmee;Title,Chaptei 9.1 115.3,anu the Sari Joaquin County Well Standards <br /> Job Address 16888 McKinley Road City/State/Zip La4hrop/CA/95330 Phone 209-858-3365 <br /> Cross Street Lague Road APN 19816026 <br /> Property Owner, Super Store Industries Phone 209-658-3365 <br /> Address _ 16888 McKinley Road _�—City/State/Zip Lathrop/CA/95330 <br /> C-57 Contractor Gregg Drilling,Inc. License# 485165 _ _ Phone 925-313-5800 <br /> Address 950 Howe Road —_ _ City/Statelzip Martinez,CA 94553 <br /> Consultant/Sub-Contractor GeosyntecConsultants,Ina License# Phone 9'5-637-8334 <br /> Address 3043 Gold Canal Dr. CitylState/Zip Rancho Cordova,CA 95670 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBOMNG NUMBER INSTALLATION TYPk CONSTRUCTION SPECIFICATIONS <br /> [n� f,1CrJl'OR>IG B ❑ H01.-DW STEM BORIr;G DEPTH y!p to 300 it big ❑BOt.TE.0 TRAFFIC BOX 0 STOWE PIPE <br /> ❑ E:TRACTICN IVapOrrNue:) ❑ HAMMERrORI N cN DIA CF BCREHCLE 8-or 6" _❑dUL7;PLE^A51>IGS❑tdUL LE'JE_'NELL CnSd,ii DIA 4"ort" <br /> ❑ SGIL V..APC•R PROBE ❑ NdUC ROTARv CASING THICr,'ESS�23�—TYPE OF,ASING R1 STEEL❑PVC ❑ OTHER <br /> ❑ SO!LBORB,G ❑ PUSH P014T(;P!CFT, '-0ND,GTORCASING Cl-8 0 N BodrgD;a: Casing Do* Casing>olr <br /> ❑ !NJEGT-ON;174;{;,x6,-UN:Mi ❑ '-INC.AUGER GRCUT SEAL DEPT- -4EUIE TyPE-0 BE USED• ❑AwGFRS ❑HOSE©PiPC — <br /> ❑ HE? i© OTHER Sono _ROUT SEAL PUMPED? 0 Yes ❑No (Nde:Wrmt m Freefall Dept is 30 FI) <br /> 'NEL"SOIL SCRING Il P'N• 'PT,F I� bW PN•J2 ROUT SPECt'r Ca.TiOtiS Ty(a,II•V <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METI­IOD:rt:IaE_CK ALL INAT APPL•rl <br /> 9 WELLS TO 3E DESTROYED _ ——�—--! ❑OVER-BORE DIAMETER o` inches to depth of reel <br /> WELL IOs ^_ — ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES rom to feet nalow su,19ce <br /> TRESIVIE TYPE TO BE USED [ AJGERS 0 HOSE 0 PIPE — MUSHROONI CAP ❑3 feet below surface or Ieetbelow sur'-we d>3Im <br /> OMMENTS: 8 monitoring wells will be Installed to a maximum depth of 300 ft togs. See attached table with well specifications. <br /> I 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 GeofogisUGeosynlec Consultants,Inc. <br /> Print Name Garrett Thornton Date June 29,2018 <br /> DEPARTMENT USE ONLY <br /> —.....- r <br /> Application Accepted By: _Date Issued.—�,��1 ��•-- __ <br /> Grout Inspection By/Dates: — V <br /> Destruction Inspection By/Dates: <br /> Facilit !Site intormation _ _ <br /> FANsmee� t _t_ r'AAdaress Ib]"I't vjp�,��pA FA# PR# 0�3CUV <br /> FA PE� J �OW���`� WP Reviewed By L_ Worx'lan Date �I22(I� i 6 <br /> ❑ 5% jjjjPC- T Aulhn Gxlu:n iu CIhs1 Ic Sigv den it NcrAeh Conc ❑worker;:cmo'uV&icer ❑=rcroernment Psrmq L�A ss i,greem el j:& Agency App,,,va! &,11"F <br /> COMMEN TSICON DI TIONS: <br /> WPTYPE PE SCk1152 <br /> FEE INFO AMT REMITTED CH9CK* RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit -&bo 31• x 5 -7bG <br /> 1868 E. Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209464-0138 1 Www.Sjcehd.com <br /> EHD 25-01 09-0-17 Site Wigetlon Wail Pe.'mll A01*21 on <br />