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USANAOAQN Environmental Health Department COUNTY- RECEIVED ogtrf Greatness grows herr SITE MITIGATION WELL & BORING PERMIT APPLICATION AUG 14 2017 For Wells and Borings Used for Contaminant Investigations and RemediBllIMRpNMENTALHEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERWCES 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 500 East Louise Avenue CitylStatelZip Lathrop,CA,95330 Phone 925.674-8400 Cross Street Harlan Road APN 198.120-08 Property Owner` RB Louise LLC,Et AL Phone 926-674-8400 Address 1200 Concord Avenue,Suite 200 —City/State/Zip Concord,CA,94520 C-57 Contractor Advanced GeoEnvironmental,Inc. License# 680227(C57) Phone 209-467-1006 Address 837 Shaw Road City/State/Zip Stockton,CA,95215 Consultant(SubContractor NIA License# Phone Address CitylStatelZip CONSTRUCTION WORK TO§E PERFORMED:*Note: Offsite Borings/Wells Require Access Agreem is or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 12 feet ❑BOLT RAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 1.25 inches ❑M PLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING TWO(2) ® PUSH POINT{GP/CPT) CONDUCTOR CASING ❑Yes ❑No ring Dla: Casing Dia: Casing Depth: ❑ INJECTION(Air Soame Oz..) ❑ HAND AUGER GROUT SEAL DEPTH 12 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes No (Note:Maximum Presto//Depth Is 30 FU WEWSOIL BORING IN '`.GROUr SPECIFICATIONS Por dcement DESTRUCTION WORK TO BE PERFORMED: D STRUCTION METHOD: CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED OVER-BORE DIAMETER of_inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS EXPLOSIVES From to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE - MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Geologist/AGE Print NameWilliam Little Date 081011A17 DEPARTMENT USE ONLY \ Application Accepted By: \Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name FA Address FA# PR# FA PE 7Z I WP Reviewed By Wodc Plan Date ❑C-57 ❑C-57 gwr.agon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMM ENTSICON DITIO NS: WP TYPE PE I SC I FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit F 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHO 29-01 IMI-17 Site Mitigation Well Permit Application