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SAN JOAQUIN Environmental Health Department <br /> ---COUNTY <br /> "I,-,; s„•:` 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 /> t <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# 254267 JLkO 7/;1/fc(- Phone (966) 942-2315 <br /> 1 <br /> Address 1016 Lincoln Blvd. City/State/Zip San Francisco, CA, 99129 ' <br /> Consultant/Sub-Contractor ENGEO, Inc. License# Phone (925) 786-7895 <br /> Address 17278 Golden Valley Parkway City/Stale/Zip Lathrop/ CA/ 95330 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offshe Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLSORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERI)RIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPICPT) CONDUCTORCASING [I Yes [I No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION fA spama.Owre) ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: - GROUT SEAL PUMPED? [I Yes [I No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELD SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 ❑OVER-BORE DIAMETER of_inches to depth of_feel <br /> WELL IDS MWR-29 and MWR-30 In PRESSURE GROUT To depth of 22 feet below sudace <br /> GROUT SPECIFICATIONS neat cement [I EXPLOSIVES From to_feetbelowsudaw <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet <br /> COMMENTS: rYQ.SS „y- � � !"'-L'7 D IeL / /Ia� el �OY1,'l sLNtLt> c�- &14C <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 �(l�y� Title/Company_Pro)ectceolcgl:uENGEo INC. <br /> Print Nama Cody Johnson Dale 09-12-2023 <br /> DEPARTMENT USE ONLY Application Accepted By: Date Issued: 'C I N)0 Z3 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dales: <br /> Facilit /SiterInformation •-� <br /> FA Name e \Jjr 5/4� t/.41 FAAddress s � FA# �v 5q PR# <br /> FA PE 1 ` X OA WP Reviewed By /� Work Plan Date Z <br /> ❑C57 7Authodzatmfor Otherlo Sgn Permit ❑Workers Comp ❑Workers Comp Waiver ❑Enaoechmenl Permit ❑Access Agreement Lead Agenq Approval MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE [p}PE SC FETE INFO AMT REMITTED CHECC`K# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit TV 313 c I A 2,r� 3 "'l o � l_ I T 00 �-q <br /> 1868 E. Hazelton Avenue I Stockton, California 95205.1 T 209 468-34401 F 209 464-0138 �ehd.com <br /> EHD29-0108-01-17 I ) V lT/ I Site Mitigation Well Pennit Application <br />