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� <br /> otq�Iry • SAN .IOAQUIN COUNTY RECEIVED <br /> 15 2015 <br /> ri --«�- '•, ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 ENVIRONMENTAL HEALTH <br /> • P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sagov.org RMITISEmACES <br /> dAIFOR�` <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 /> 500 East Louise Avenue citylstate/zip Lathrop, 95330 Phone <br /> Jot Address 198-120-08 <br /> Harlan Road AP" 925-674-8400 <br /> Cross Street phone <br /> Property Owner' RB Louise LLC, etal <br /> Address <br /> 1200 Concord Avenue, Suite 200 CitylStatelZip Concord, CA 94520 916-363-9355 <br /> C-57 Contractor All Well Abandonment License# 848359Phone <br /> citylst r e/zip Sacramento, 95742 209-467-1006 <br /> Address 9245 Beatty Drive Suite A Phone <br /> ConsultantlSub-Contractor AGE License# <br /> Address <br /> 837 Shaw Road city/state/Zip Stockton,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ®BOLTEDTRAFFIC BOX ❑STOVEPIPE <br /> ❑ MONITORING 0 HOLLOW STEM BORING DEPTH <br /> X(EXTRACTION(VaporMlater) �❑ HAMMEWDRIVEN DIA.OF BOREHOLE 10 inches E OFICASING:I❑ MULTI-LEVELWELL <br /> PVCE❑ OTHER <br /> SING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Casing Dia: Casing Depth: <br /> [3 ❑ <br /> SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING Yes ®No Bodng TREMIEITYPE TO BE USED'. ®AUGERS ❑HOSE ❑PIPE <br /> [I INJECTION IAYS e0zonel ❑ <br /> HAND AUGER GROUTSEAL DEPTH <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yes 19 No (Nate:Maximum Freefall Depth is 30 Fry <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS <br /> portland <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD-(CHECK ALL THAT APPLY) <br /> ❑OVER-BORE DIAMETER of_inches to depth of_feet <br /> #WELLS TO BE DESTROYED ❑PRESSURE GROUT To depth of_feet below surface <br /> WELL IDs C]EXPLOSIVES From_to_feel below surface <br /> GROUT SPECIFICATIONS MUSHROOM CAP El feet below surface surface or feet below sudace if>3 feet <br /> TREMIE TYPE TO BE USED 11 AUGERS ❑HOSE ❑PIPE E] <br /> COMMENTS: 37.806791 -121.288790 <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Jf aqu County Ordinance Codes and Standards,and all other applicable California laws. <br /> � Title/Company geologist/AGE <br /> Signed �LGp t if 09115115 <br /> Print Name <br /> William Little Date <br /> DEPARTMENT USE ONLY ?Z2 <br /> jZ� <br /> Date Issued: T <br /> Application Accepted By: /V&ez -�-✓-� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information FA# PRO <br /> FA Name FA Address <br /> WP Reviewed By Work Plan Date <br /> FA PE <br /> ❑057 ❑C-57 Aulhonzatkin for Other to Sign Pem�fl ❑Workers Camp ❑worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval <br /> ly,, MFR <br /> COMMENTSICONDITIONS: ' I„ L ,(9 toy ( .�y��7 <br /> SR TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY q DATE SERVICE REQUEST# r rIN_VIOICE# <br /> Work Plan ZP3 596 — 390- <br /> 2, p/ 15- <br /> �+ pR 00 3200 <br /> Permit z901 <br /> Site Mitigation Well Permit Application <br /> EHD 29-016-23-2015 <br />