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SAN _JOHNN EnvironmeAI Health Department -COUNTY Greotness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 17100 Murphy Parkway City/State/Zip Lathrop,CA,95330 Phone 925.674-8400 Cross Street Harlan Road APN 198-120-09 Property Owner' RB Louise LLC,Et Al. Phone 925.674-8400 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/StatelZip Stockton,CA,95215 Consultant/SubContractor N/A License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsMells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 12 feet Cl BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWater) D HAMMER(DRIVEN DIA.OF BOREHOLE 1.25 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 12-13 ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boning Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air somae.Corel ❑ HAND AUGER GROUT SEAL DEPTH 12 feet TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Malmum Freefall Depth Is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION 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 El EXPLOSIVES From to feet 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 Joaqui Coun ante Codes and Standards,and all other applicable California laws. Signed b�/ 'u'g yrs 7j Title/Company Geologist/AGE Print NameWilliam Little Date 08101/2017 DEPARTMENT USE ONLY Application Accepted By: - e"/ -mak Date Issued: y/7. - Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name _ �wttNAY.�Sri P FA Address ,rt I.00 MP FA# 00v" V—P PR# ile FA PE � WP Reviewed By Work Plan Date C-57 ❑C-57 Authorization for Other to Sign Permit 1114V&ker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement 2<eadAgencyApipmal 4NFR COMMENTSICONDITIONS: 'WP'TYPE PE SC I FEE INFO JAMT REMITTED1 CHECK#I RECV-D BY DATE WELL PERMIT# INVOICE# Permit I 2`1bS 7y", $152 x 3 � NSlo t3011 I 1--Y W P(70 11 6W�& 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 0e-01-17 site Mitigation Well Permit Application