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ip <br /> 8SAN JOAQUIN COUNTY 0ENVIRONMENTAL HEALTH DEPARTMENT ��1868 Hazelton Avenue, Stockton, CA 95205-6232p�,,�Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sicehd.comp �f <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION rT�s RTy yFq�T <br /> For Wells and Borings Used for Contaminant Investigations and Remediation SFS <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 500 East Louise Avenue City/statelzip Lathrop,95330 Phone 925-674-8400 <br /> Cross Street Harlan Road APN 19&140-16 <br /> Property Owner* RB Louise LLC,etal Phone 925-674-8400 <br /> Address 1200 Concord Avenue,Suite 200 City/State/Zlp Concord,CA,94520 <br /> C-57 Contractor Advanced GeoEnvironment Inc. License# A Haz C57-680227 Phone 209-467-1006 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA 95215 <br /> Consultant/Sub-Contractor N/A License# Phone <br /> Address Cky/State2lp <br /> CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offs BoringsANells Requi Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE NSTRU TI SPE IFI N <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporM'ater) ❑ HAMMERA)RIVEN DIA.OF BOREHOLE inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNES TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> n SOIL BORING _rWD9Y PUSH POINT(GP/CPT) CONDUCTOR C NG M ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air soarae.omne) ❑ HANDAUGER GROUTSE EPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROU AL PUMPED? ❑Yes No (Note:Maximum Freetal Depth is 30 FU <br /> WEW SOIL BORING IDs G T SPECIFICATIONS portend nt <br /> DESTRUCTION WORK TO BE PERFORMED- DESTRUCTION M HOD: CHECK ALL THAT APPLY <br /> If WELLS TO BE DESTROYED ❑OVER-BORE IAMETER of_inches to depth of feel <br /> WELL IDs ❑PRESSURE GROUT To epth offeet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS HOSE ❑PIPE ❑MUSHROOM CAP —[_]3 elm surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby a ify that I am authorized to complete this application and that the work will done in accordance with <br /> a�Joa in my Ordinance Codes and Standards,and all other applicable ilifornia laws. <br /> Signed Title/Company Geologist/AGE <br /> Print Name 1Nilliarq ittle 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 /> Facll /Site Information ,n <br /> FA Name 'Zp�] Ltwtyl. FAAddress Sb.7 G 1.,,,�„v"ye, {�.�/e wwG FAq �L�t�'�e� PF4 U$-N'ZQ 8vv <br /> FA PE a- WP Reviewed By _ Wok Plan Dale "7 1 DH 11 <br /> 7 <br /> C-57 [I C-57 Authorization for Other to Sign Permit Workers Comp ❑Workers Comp Waiver ❑Encroachment Perma ❑Access Agreement l73<eadAgencyAppmvaI MQFR <br /> COMMENTS/CONDITIONS: CAM C-1 kA--S I ,, 4tAAWV-L-CJt <br /> SR TYPE I PE I SC FEE INFO AMT REMITTED CHECK#I RECV'DBY PATE SERVICE REQUEST# INVOICE#` <br /> Permit a lob 1 i3 s. x � S o j t )0'i L._"� Y V003-7015 <br /> K)P 2°103 Sz-3 t I5z-y 3 H56 -AD q-1 t-X Kla)t 1 S(LOC1 003 <br /> EHD 29-01 10-26-2015 Site Mitigation Well Permit Application <br />