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SAN JOAOUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />RECEIVED <br />SITE MITIGATION WELL & BORING PERMIT APPLICATNvilp7oNmEn4GivisNE1TRAL:HIEAL7s TH <br />For Wells and Borings Used for Contaminant Investigations and Remgdiation <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 Golden Valley Parkway city/state/zip Lathrop, CA 95330 Phone <br />Cross Street Spartan Way APN 191-210-08 <br />Property Owner* Saybrook CLSP, LLC Phone (650)632-4522 <br /> <br />Address 303 Twin Dolphin Drive, Suite 600 city/state/zip Redwood Shores, CA 94065 <br />C-57 Contractor Confluence Environmental, Inc. License# 913194 Phone (916)760-7641 <br />Address 3308 El Camino Ave, Suite 300 #148 city/state/zip Sacramento, CA 95821 <br />Consultant/Sub-Contractor HydroFocus, Inc. License# Phone (530)759-2484 <br /> <br />Address 2827 Spafford Street <br /> <br />City/State/Zip Davis, CA 95618 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORING NUMBER INSTALLATION TYPE <br />El MONITORING 1 x HOLLOW STEM <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN <br />SOIL VAPOR PROBE 0 MUD ROTARY <br />SOIL BORING 0 PUSH POINT (GP/ CPT) <br />0 INJECTION (Air spurge, Ozone( 0 HAND AUGER <br />OTHER 0 OTHER: <br />WELL/ SOIL BORING IDs CLSP-11 <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 24 ft 131 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 10 in U MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 12(1 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes No Boring Dia: Casing Die: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: FS AUGERS ID HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes El No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS neat cement sanitary seal - 10 ft <br />additional 2 ft bentonite transition seal below sanitary seal <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />ID OVER-BORE DIAMETER of inches to depth of feet <br /> I=1 PRESSURE GROUT To depth of feet below surface <br /> El EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP 03 feet below surface or feet below surface if >3 feet <br /> <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br /> <br />TREMIE TYPE TO BE USED E AUGERS 0 HOSE PIPE <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 />Signed <br /> <br />Title/Company Confluence, Inc. <br />Print Nam Josh Kerns Date 8/9/17 <br /> <br />PARTMENT USE ONLY <br /> <br />Vat I / <br /> <br />Application Accepted By: <br /> <br />Date Issued: <br /> <br />Grout Inspection By/Dates: t-- <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name <br />i7r.' -ts, Vtivi(.4....,An.J1 LA-1,...,1 FA Address (.7-4 itkiv•. kritAkel e'4144,`T'l FA# 0 OLA NA, PR# <br />FA PE 'C--WP Reviewed By l...._ ---,..>e Work Plan Date k k. 11 7- ri I 1,0 <br />ifK57 0 C-57 Authorization for Other to Sign Permit 191Vorkers Comp 0 Workers Comp Waiver 0 Encroachment Permit ii‘cess Agreement E‘d Agency Approval li;k1gR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit .)•4101 $)1 $152x I 1 62- Tr96 L --X iii (1 Of 0o31w10 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application