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RECEIVED cP4 t SAN JOAQUIN COUNTY I�? ED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' AUG 25 2016 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.smcehd.com ENVIRONMENTAL. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATMH DE`"'''T` "IJ <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 Village Ave(37.80879 -121.307) City/State/Zip Lathro0 CA 95330 Phone <br /> Cross Street Forty Niner Trail APN Right-of-wary <br /> Property Owner• City of Lathrop I Phone (209)941-7200 <br /> Address 390 Towne Centre Drive City/State/zip Lathro CA 95330 <br /> C-57 Contractor Confluence Environmental Inc License# 913194 Phone (949)716-4971 <br /> Address 3308 EI Camino Ave. Suite 300#148 City/Statal[ip Sacramento 95821 <br /> ConsultanVSub-Contractor Hydro Focus Inc. License# Phone (530)759-2484 <br /> Address 2827 Spafford Street City/State/Zip Davis CA 956 8 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC SO ❑STOVEPIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI,LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑S.EEL ❑PVC ❑ OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes 0 N Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(M Seam.Omnel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [I HOSE El PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes 11 No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELUSOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE Of METER of_inches to depth of feet <br /> WELL IDs MWM- 16 E PRESSURE GROUT_fO depth of 21 feet below surface <br /> GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED []AUGERS ❑HOSE 0 PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel belay surface if>3 feel <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 /> ff//�San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> `t4'�yB"t'L•'�-� <br /> Signed � Title/Company President/Confluence Environmental <br /> Print Name Megan Kerns Date 8/23/2016 <br /> ,r DEPARTMENT USE ONLY <br /> Application Accepted By: /// rs< Date Issued <br /> Grout Inspection By/Dales: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# 232/4 PR# OT�fD � <br /> FA PE WP ReNewed By /J/� �rr,Gr Work Plan Date / 5 /6 <br /> 1 7 ❑C-57Authorization far Other(o Sign Permit orkers Comp ❑Workers Comp Waiver ncrewhment Permit ❑A sAgreement ❑Lead gencY Approval El VIER <br /> COMME NTS/CONDf TIONS: <br /> SR TYPE PE sC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE I �!I SERVICE R—E—OU—E—S—T—# 7 INVOICE# <br /> Work Plan ct /. <br /> Permit 29,02 313 $13y- ,J 7 rj' " gy9y 641VT g�%G Ii��Jrcf/C71o00 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />