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Cross Street Paradise Road ApN 213-23-004-4- <br />C-57 Contractor V&W Drilling (209 Phone License# 720904 469-7700 <br />City/State/Zip Stockton, CA 95215 <br />Phone (2091684-7604 Consultant/Sub-Contractor ENGEo, Inc License# <br />City/State/Zip Lathrop/ CA / 95330 Address 17278 Golden Valley Parkway <br />CI Yes 0 No <br /><1 foot <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? DYes 0 No <br />GROUT SPECIFICATIONS Cement <br />Ana Lea Print Name Date 07/14/2017 <br />DEPARTMENT USE ONLY <br />7 Date Issued: Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Date <br />Facility/Site Information <br />/144.-- 2}// 7 <br />st- 0 7 0/ <br />Site Mitigation Well Permit Application <br />/ <br />4 9:52— EHD 29-01 10-26-2015 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.M cFRONMENTAL HEALTH <br />SITE MITIGATION WELL & BORING PERMIT APPLICATISITIT/SERVICES <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />\•••lelle alligi.i <br />`.i- . .. • • 0'/ <br />-4,i'g 6'1313— <br />RECEIVED <br />JUL 1 9 2017 <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 16476 Cohen Road City/State/Zip Lathrop/ CA/ 95330 Phone <br />Property Owner* River Islands Development LLC Phone (209)979-7900 <br />Address 9 `.12 t r9q C>C1 fAC._ 4ct, City/State/Zip ‘a-Uki-ottal-; / 941-A CIS-417 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING <br />MONITORING <br />EXTRACTION (Vapor/Water) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Alr seam. °ono <br />OTHER <br />WELL/SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> o HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> o PUSH POINT (GP/ CPT) <br /> o HAND AUGER <br />El OTHER <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED I <br />WELL IDs MWR-8 <br />GROUT SPECIFICATIONS neat cement <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 1E1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of 8 inches to depth of 20 feet <br />0 PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <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 />Title/Company Staff Engineer/ENGEO, INC. Signed <br />FA Name <br />--, . <br />!Civ,(4.- ) sico.,42,0 FA Address /476 65Le, ill FA1 ([J, , pR# . _ as77 Log <br />FA PE .'71 0 WP Reviewed By <br />ifl/°-- <br />Work Plan Date -7 io .---7 <br />57 0 C-57 uthorization for Other to Sign Permit tp‘rker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead A ncy Appro I l!WaR <br />COMMENTS/CONDITIONS: Terv,:f )---v...,3A- <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE . SERVICE REQUEST# I NVOICE# <br />Permit eio 7, <br />lz, <br />3/) $J.,39--X $ i—C-2--- )20347 (47 7/z kik:42 Ct :".7,67 ,Sci 2- <br />Address 3806 Duck Creek Drive