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SAN JOAQUIN Environmental Health Department <br /> _ —COUNTY— <br /> "I,rrooO Greatness grows here. <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 /> 48 Hours Advance Notice Required For All Inspections <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 Stewart Road City/State/Zip Lathrop/ CA/ 95330 Phone <br /> Cross Street S Paradise Road APN213-63-001 <br /> Property Owner* River Islands Development LLC Phone (209) 879-7900 <br /> Address 73 Stewart Rd City/State/Zip Lathrop/ CA/ 95330 <br /> C-57 Contractor Geo-Ex License# 954267 JL)c/Q 7/31/?W Phone (966) 942-2315 <br /> r <br /> Address 1016 Lincoln Blvd. City/State/Zip San Francisco, CA, 94129 <br /> Consultant/Sub-Contractor ENGEO, Inc. License# Phone (925) 786-7895 <br /> Address 17278 Golden Valley Parkway City/State/Zip Lathrop/ CA/ 95330 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELDBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapoewater) ❑ HAMMERNRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL [I PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION tAYsran ouee) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [I PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEA.PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELD SOIL BORING IOs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: 7CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 ❑OVER-BORE DIAMETER of_inches to depth of feet <br /> WELLIDs MWR-29snd MWR3o ®PRESSURE GROUT To depth of 22 feet below surface <br /> GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From to feel below surface <br /> TREMIE TYPE TO BE USED El AUGERS ❑HOSE IXI PIPE ❑MUSHROOM CAP ❑3feetb lloow"s'utrfface or. 'J feet below surface if>3 feel <br /> COMMENTS: Key V1� yt �'7i D K I A�� 2l CtlrVtstMtGtA'2c� SFI�J <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> /San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed Title/Company Prolect GeolNiel ENGEO,INC. <br /> Print Name Cadr Johnson Date os-lz-zoza <br /> DEPARTMENT USE ONLY ���]T ­7 <br /> Application Accepted By: Date Issued: — / G0 �� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: zs <br /> Facilit /Sitet (Information <br /> FA Name rt.1er 5/wv1 �E 1 FA Address FA# LIV Z� PRq o(;gq' 6 <br /> FA PE I ` 09 6 WP Reviewed By 3 Work Plan Date / Z <br /> ❑C57 7Authorizagon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Pennit ❑Access Agreement Le ad AgmWApproval KMFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE I PE I SC + FEE INF�O7 AMT RE/MIITTED CHE/C`K# RECV'D BY /DATE WELL PERMIT# INVOICE# <br /> Permit qo 313 t ` 21L I., �[ o l_ / % �Z L� s5dO <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0738 l �ehd.com <br /> EHD 29-01 OMl-17 AA I j 9 �e G2 qI / Site Mitigation Well Permit Applimlbn <br />