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r <br /> i SAN JOAQUIN Environmental Health Department <br /> --COUNTY- - <br /> (�reo ines> grow ircrc. <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 ! e J <br /> 48 Hours Advance Notice Required For All Inspections 77 J <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor 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 500 East Louise Avenue CltylStatelZip Lathrop,CA,95330 Phone 925.674.8400 <br /> Cross Street Harlan Road APN 199A86-000 tq 9! ?,04 <br /> Property Owner* ASPIRWM Properties LLC,RBB Loulse and Delta LLC Phone 925.674-8400 <br /> Address 1200 Concord Avenue Suite 200 City/State/Zip Concord,CA,94520 <br /> C-57 Contractor ADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209467-1006 <br /> Address 837 SHAW ROAD City/Stale/Zip STOCKTON,CA 95216 <br /> ConsultanUSub-ContractorADVANCED GEOENVIRONMENTAL,INC. License# 680227 Phone 209467-1006 <br /> Address 837 SHAW ROAD CltylState2lp STOCKTON,CA 96216 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Oftsile BodngsAArells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELUBORING NUMBER INSTALLATION TYPE C NSTRUCTIOt19—PECintATIONS <br /> [] MONRORING ❑ HOLLOWSTEM BORINGDEPTH I 70- []BOLTED TRAFFIC BOX ❑STOVEPIPE <br /> ❑ EXTRACTION(VapeaWa(er)C_=:_A0 <br /> ❑ HANJAWRNEN DWOFBOREHOL 1.5 ❑MULTIPLE CASINGS[]MULTI-LEVELVIELLCASINGDIA <br /> ❑ SOILVAPORPRO13E 13 MUD ROTARY CASINGTHICKNESS TYPE'OF CASING: []STEEL❑PVC[]OTHER <br /> N SOILBORING PUSHPOINT(SP/CPT) CONDUCTORCASING ❑Yes []No BaMp Dia: Cwtn9 Die: Camp Depth: <br /> ❑ INJECTION pYsoaroaane HANDAUGER GROUTSEALDEPTH 10(eel THEME TYPE TO BE USED: []AUGERS ❑HOSE ®PIPE <br /> [IOTHER OTHER GROUT SEAL PUMPED? []Yes NNo (Note:Mamxxn Freefall Depth is 30 R) <br /> WELD SOIL BORNG IDs GROUT SPECIFICATIONS PAand Cement 60abns per 94lbs sack <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APEM <br /> If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of—"as to depth of_feet <br /> WELL IOs ❑PRESSUREGROUT To depth of—feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS HOSE PIPE MUSHROOM CAP 3 feet below surface or (eel baba surface if>3(set <br /> COMMENTS:SEE RWQCB APPROVED WORK PLAN DATEgp 01 AUGUST 2018 <br /> \l 11 1 L 16 D-0111•�'}{cc14) <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Jg4quin County Ordinance Codes and Standards,and all other applicable California laws. <br /> it/✓//1 1 <br /> Signed � v--, TltlelCompany PROJECT MANAGER/A.G.E. <br /> Print Name Brian Millman Date 19 December 2019 <br /> EPART N SEONLY tt /Z <br /> Application Accepted By: OalelfssuedW' <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: 42 lz,2,1,)2nm <br /> acili ISI a Information t '/ 1 f may\ <br /> FA Name 9CV ,,,,.I^ /�N'y Al FA Address s� G. COul' FA# Ol 3 PR# 5 (/ Zg <br /> FA PE ZQ,^v&5 P Reviewed By Work Plan Date 1� `�� �� <br /> C57 ❑057AUthabaUmfor OlherbSgn Permit ❑Reefs Carp ❑Wakens CanpWaver []Encroachment Pamil []AecelsAyeemenl ❑Lead ApencyAwoval ❑3 ' <br /> MFFR <br /> C/nO�M EN,T,SIoCONDITIONS: Su bM f Q r epy- /,kio 7� a Wj II A �` OLA/S 6 4AKo <br /> WP TYPE PE I SC I FEE INFO JAMT REMITT D CHECK# RECV-D BY I DA E WELL PERMIT# INVOICE# <br /> Penult 152 x /.� IZ Zg 22 <br /> 1868 . Hazelton Avenue I Stockton. California 95205 1 T 209 468-3420 1 F 209 4 4- Q Pvtm. odhd.conT <br /> EHD29010601-17 Site Millpaflw WeePa AWP Ilon <br />