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SAN JOAQUIN <br />110 <br />Greorness grows her <br />COUNTY <br />Signed <br />Print Name Se. <br />Environmental Health Department <br />rn z <br />io m 7.7 <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediatiorii; <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. c !— <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County VII Standard0 <br />0 <br />City/State/Zip Lathrop, Ca Phone <br />APN 198-379-3834 <br />Job Address <br />Cross Street <br />Murphy Parkway <br />D'Arcy Parkway <br /> <br />Property Owner*R&B Louise, LLC et al (attn: Dana Parry) <br />Address do Reynolds and Brown, 1200 Concord Ave, Suite 200 City/State/Zip Concord, Ca 94520 <br />C-57 Contractor Cascade Drilling L.P. License# 938110 <br />Phone (925) 674-8400 <br />Phone (510) 478-0858 <br />Address 120 S. 23rd Street City/State/Zip RiChMon 9 04 <br />Consultant/Sub-Contractor Arcadis U.S. Inc <br />Address 101 Creekside Ridge Court, Suite 200 <br />License# <br /> <br />Phone 1916) 865-3135 <br /> <br />City/State/Zip o ev e, 95678 <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Aoqess Ag ments or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM BORING DEPTH <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE D <br />El SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes a No od <br />El INJECTION (Air Spam, Ozone( 0 HAND AUGER GROUT SEAL DEPTH T E <br />OTHER 0 OTHER: GROUT SEAL PUMPED? Yes V No (N <br />WELL/ SOIL BORING IDs GROUT SPECIFICA -. <br />•E <br />e. <br />C S <br />FIC BOX 0 STOVE PIPE <br />C INGS ID MULTI-LEVEL WELL CASING DIA <br />G: 0 STEEL 0 PVC 0 OTHER <br /> Casing Dia: Casing Depth: <br />E TYP TO BE USED: D AUGERS 0 HOSE 0 PIPE <br />aximum Freefall Depth is 30 Ft) <br />BO DT <br />aLP <br />GROUT SPECIFICATIONS Neat cement grout <br />TREMIE TYPE TO BE USED P AUGERS HOSE E PIPE-- <br />COMMENTS: <br />ClifidON METHOD: (CHECK ALL THAT APPLY1 <br />ORE DIAMETER of inches to depth of feet OE <br />PR SURE GROUT To depth of 218 feet below surface <br />PLOSIVES From to feet below surface <br />(jilvIUSHROOM CAP IX 3 feet below surface or feet below surface if >3 feet <br />DESTRUCTION WORK TO BE PERFORMED: DE <br /># WELLS TO BE DESTROYED Six <br />WELL IDs EW-04, EW-04A, INJ-14, PW08-076, PW08-1557P -180 Fiq <br />• <br />I hereby certify that I am authorized to plete this application and that the work will be done in accordance with <br />San Joaquin County Ordina ce Codes and Standards, and all other applicable California laws. <br />Title/Company C / (coot. 5 <br />Date 8.- I t - r1 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name / FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp ID Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <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