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41 <br /> • SAN JOAQUIN COUNTY ` RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT AUG 25 2016 <br /> : ° '• 1868 Hazelton Avenue, Stockton, CA 95205-62 2 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sicehd.com ENVIRONMENTAL <br /> 4l I F OYt" <br /> SITE MITIGATION WELL & BORING PERMIT APPLICA-fibikH OEIARTIIENT <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Barbara Terry Blvd(37.81554,-121.305) City/State/ZIP athrop, CA 9 330 Phone <br /> Cross Street Adobe Way APN Right-of-way <br /> Property Owner" City of Lathrop Phone (209)941-7200 <br /> Address 390 Towne Centre Drive City/State2ip Lathrop. CA 9 330 <br /> C-57 Contractor Confluence Environmental Inc. License# 913194 Phone (949)7164971 <br /> Address 3308 EI Camino Ave. Suite 300#148 city/statdZip Sacramento CA 95821 <br /> Consultant/Sub-Contractor Hvdrofocus Inc. License# Phone (530)759-2484 <br /> Address 2827 Spafford Street City/Statdzip Davis CA 956 8 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/water) ❑ HAMMERARIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS P MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: C1 S-EEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING El Yes [I No Boring Dia: Casing Dia: Casing Depth <br /> ❑ INJECTION Wraoaoe.Ozonel El HAND AUGER GROUT SEAL DEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE Dyk�v1ETER of_inches to depth of feet <br /> WELL IDs MWM-26 ■PRESSURE GROUT o depth of 21 feet below surface <br /> GROUT SPECIFICATIONS neat Cement ❑EXPLOSIVES Fromo_feet below surface <br /> TREMIE TYPE TO BE USED El AUGERS ❑HOSE 0 PIPE El MUSHROOM CAP [-]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 /> �,��,n ,"� 167SJoaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed -• 7 Title/Company President/Confluence Environmental <br /> Print Name Megan Kerns Date 8/23/2016 <br /> yJ_' DEPARTMENT USE ONLY <br /> Application Accepted By: ILI�,�Lr � Date Issued: <br /> z <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FAName AAddress FA# Z3 Z 16 PR# OSOSSB <br /> FA PE WP R ed By ,,Il Work Plan Date 1 <br /> G57 <br /> [I C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver UEfGnaachmentPermit ❑Access Agreement ad Agency pproval 2 FR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECv'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit Z90 Z 3f j $139 X /39 ` RN 'Ni Jt F-125))L R,76 Z�oD � <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />