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i <br /> RECEIVED <br /> o04u(/y. SAN JOAQUIN COUNTY AUG 2 5 2016 <br /> ENVIRONMENTAL HEALTH DEPARTME T <br /> N <br /> : � • 1868 Hazelton Avenue, Stockton, CA 95205-62 2 ENVIRONMENTAL <br /> �d :P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www sicehd.com HEALTH DERA9TMF_NT <br /> �rFO <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <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 121 East Louise Avenue City/State/Zip _Lathrop, CA 95330 Phone <br /> Cross Street Golden Valley Parkway APN right-of-way <br /> Property Owner* City of Lathrop Phone (209)941-7200 <br /> Address 390 Towne Centre Drive City/StatelZip Lathrop,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/State/Zip Sacramento C N 95821 <br /> Consultant(Sub-Contractor HydroFocus, Inc. License# Phone (530)759-2484 <br /> Address 2827 Spafford Street City/StatdZip Davis CA 95618 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreemen s or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI OPT) CONDUCTOR CASING ❑Yes 0N Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Alt So,.0mne) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑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 M OVER-BORE - DIAMETER of 8 inches to depth ofd feet <br /> WELL IDs CLSP-4 ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS neat cement El EXPLOSIVES From_ o_feet below surface <br /> TREMIE TYPE TO BE USED 0 AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below urface 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 /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company President/Confluence Environmental <br /> Print Name Megan Kerns <br /> Date 8/23/2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: Az <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: l <br /> Facili /Site Information <br /> FA Name FA Address FA# 02321 PR# O gOsB� <br /> FA PE WP 'awed By /V/e/ �3vn Work Plan Date I / S" /F <br /> G57 ❑C-57 Authodiration for Other to Sign Permit orkefs Comp ❑Workers Comp Waiver 26crowhment Permit ElAocessAgneement ead Agency Approval I-iJ•MF(t <br /> COMME NTSICON DITIONS: <br /> SR TYPE I PE SC FEE INFO AMT REMITTED I CHECK#I RECV'D BY I DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 0902 313 $13�x jC',0---t' I � 4Jk 5R007�006 <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />