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SAN�IOAQ�N Environmental Healthr�t ent ��j —COUNTY— rIVED 70 Greatness grows herc AUG 14 2017 SITE MITIGATION WELL & BORING PERMIT APPLIC Tl NWNTALHE For Wells and Borings Used for Contaminant Investigations and Remedia IT/SERVIC$TM 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/State/Zip Stockton,CA,95215 ConsultanVSubContractor All Well Altandonment License# 848359 Phone 916.363-9355 Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova,CA 95742 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX [I STOVEPIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVENN DIA.OF BOREHOLE El MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY ASING THICKNESS TYPE OF CASING: ❑STEEL C1 PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CDUCTOR CASING El Yes [I No Boring Dia; Casing Dia: Casing Depth: [I INJECTION(M eoaae.Omnel [IHAND AUGER G SEAL DEPTH 12 fast TREMJEITYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUTL PUMPED? ❑Yes El No e:Maximum Revisit Depth is 30 Ft) WEWSOIL BORING IDs GROUT SP FICATIONS PoNantl cen DESTRUCTION WORK TO BE PERFORMED: ES UCTION METHOD: CHECK ALL THAT APPLY If WELLS TO BE DESTROYED 1(one) VER-BORE DIAMETER of TWO inches to depth of 20 feel WELL IDs W-1 SSURE GROUT To depth of—feet below surface E;2'GROUT SPECIFICATIONS ❑EX SIVES From lo_feet below surface TREMIE TYPE TO BE USED ®AUGERS [-]HOSE [-I PIPE ❑MUSH OM CAP ❑3 feet below surface or feel below surface if>3 feet COMMENTS:Well Destruction I hereby certify that I am authorized t complete this application and at the work will be done in accordance with San Joaquin County Ord' ance Codes and Standards,and a other applicable California laws. Signed Title/Company Geologist/AGE Print NameWilliam Little Date 08114/2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Site Information FA Name FA Address FA# PR# FA PE - WP Reviewed By Work Plan Date ❑C-57 El C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Appmval ❑MFR CO M ME NTS/CONDITIONS: WP TYPE I PE I SC I FEE INFO JAMT REMiTTED1 CHECK#I RECWD BY DATE WELL PERMIT# INVOICE# Permit $152x 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