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"In• • SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> •16"' <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*cehd.com <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 17100 Murphy Parkway City/State/Zip Lathrop,95330 Phone 925-674-8400 <br /> Cross Street Harlan Road APN 198-120-09 <br /> Property Owner* RB Louise LLC,etal Phone 925.674-8400 <br /> Address 1200 Concord Avenue,Suite 200 Citylstateizlp, ncord,CA,94520 <br /> C-57 Contractor Advanced GeoEnvironmental,Inc. Licenseft�AHaz C57-680227 Phone 209-467-1006 <br /> Address 837 Shaw Road CitylState/Zip Stockton,CA 95215 <br /> ConsultanVSub-Contractor N/A ;License# Phone <br /> Address ,xf City/State/Zip <br /> �/ <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offst ile BoringsNvells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE ON RR TINPECIFIC T,A IONS <br /> ❑ MONITORING ❑ HOLLOW STEM B ING DEPTH eet ❑BOLTED TRAFFIC BOX ElSTOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) 0 HAMMERiDRIVEN ZIA.OF BOREHOLE Iwuindle5, ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 0 SOILBORING ��IIX PUSH POINT(GP/ CONDUCTORCASIN ❑ <br /> G Yes ❑No Boring Ola: Casing Dia: Casing Depth: <br /> ❑ INJECTION IAr spare.on,t ❑ HAND AUGER GROUT SEAL DEPTH \'TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No 'I Jere:Maximum Freefall Depth Is 30 Ft) <br /> WEW SOIL BORING IDs GROUT SPECIFICATIONS PoMwid cement \\ <br /> 4\ <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH <br /> GID:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED i ❑OVER-BORE DI ETER of_inches to depth offeet <br /> WELL IDs ❑PRESSURE GROUT To dei 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 b'dlQw surface or feet below surface if>3 feel <br /> COMMENTS: <br /> I herelb l certify that I am authorized to complete this application and that the work will be don n accordance with <br /> San Jo q itcounty Ordinance Codes and Standards,and all other applicable Callfo laws. <br /> Signed Title/Company Geologist/AGE <br /> Print Name V m Little Date 07/20/17 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Faclll /Site Information <br /> FA Name L^"S - Qx, ' vSs P FA Address I�I490 ,Mw✓ ro.✓k.,,.r FA# (907 -ij "I C;' PR# c'S/•Y <br /> f 1L'L> <br /> FA PE NP Reviewed By Work Plan Date '7 Jt0 -7 <br /> C-57 El C-57 Auemdzadon for Other to Sign Permit orker's Comp ❑Worker's DanD Waver ❑Encmachmenl Permit ❑Access Agreement PleadAgencyApproval FR <br /> COMMENTS/CONDITIONS: ,'to--•i 0-avct wvse` `°" , <br /> SR TYPE I PE I SC I FEE INFOAMFT REMITTED CHECK# RECV'D BY ATE SERVICE REQUUEST# INV OICE# <br /> Vcs � <br /> Permit � 11 "X a J j-ou 'oil L-X111111\ 0310 I <br /> WP1> St3 ts2 � 3 $ 'i5b Z3W1 VX P13)l I Ra7� $ut)3 <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />