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ip <br /> SAN JOAQUIN COUNTY 0RIS VEDENVIRONMENTAL HEALTH DEPARTME14TAUG 25 2016 <br /> 1868 Hazelton Avenue, Stockton, CA 95205-62 2 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:wwn I y.sfficehicl.com ENVIRONMENTAL <br /> SITE MITIGATION WELL & BORING PERMIT APPLICAIHOINWH DEQ4-750"MT <br /> For Wells and Borings Used for Contaminant Investigations and Remediation <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE SSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or insi all the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,an I the San Joaquin County Well Standards. <br /> Job Address Rail Way(37.80701 -121.31) City/State/Zip Lathrop.CA 9 330 Phone <br /> Cross Street Village Ave APN Right-of-way <br /> Property Owner* City of Lathrop Phone (209)941-7200 <br /> Address 390 Towne Centre Drive city/State/Zip Lathrop CA 9 330 <br /> C-57 Contractor Confluence Environmental Inc License# 913194 Phone (949)716-4971 <br /> Address 3308 EI Camino Ave. Suite 300#148 City/State/Zip Sacramento (7A 95821 <br /> Consultant/Sub-Contractor HydroFocus. 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 BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BO ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: C1 S1 EEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes 0 N Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION fATSwo ozanel ❑ HAND AUGER GROUT SEAL DEPTH TREMIETYPETO BE USED: [I AUGERS [I HOSE ❑PIPE <br /> ❑ OTHER [I OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nate:Maximum Freefel IN is 30 Ft) <br /> WELUSOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK LL THATAPPL <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of inches to depth offeet <br /> WELL IDs MWM-14 0 PRESSURE GROUT To depth of 21 feet below surface <br /> GROUT SPECIFICATIONS neat cement [I EXPLOSIVES From_to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ■PIPE ❑MUSHROOM CAP ❑3 feel below urface or feet below surface if>3 feet <br /> COMMENTS: <br /> 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 � Title/Company President/Confl�ence Environmental <br /> Print Name Megan Kerns Date 8/23/2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name FA Address FA# 00 Z.321L PR# 06-.q 05 <br /> FA PE WP viewed By y ,rj. 'l Work Plan Date / /F <br /> 21,557 ❑C-57Authorization for0therto Sign Permit orkers Comp ❑Workers Comp Waiver 2&roacfimemP9nmIt ❑A ss Agreement ea6Agency Approval FR <br /> COMME NTS✓CON DITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit Z9ot, 313 s1ix I 9>qP( CV7-e R125-JA f4f40071,005/s00l` <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />