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�i • o?°''''" c SAN JOAQUIN COUNTY 1.1_' ENVIRONMENTAL HEALTH DEPARTMENT LOP .y :: =.. 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION a•. - P Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sigov.orgleh UNIT IV 4 ,i FaRSa WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Standards of the San Joaquin County Environmental Health Department. Site Location 600 East Louise Av�ioss street Harlan Road c;ty Lathrop Zip 95330 APN 198-120-09 PropertyRB Louise LLC, etal 1200 Concord Ave Suite 200 Concord, CA 94520 9256748400 s Owner Address city Zip Phone C-57 contractor AGE Address 837 Shaw Road city Stockton,CA Li, 680227 Phan.2094671006 Consultant/Sub Cnt�ll well Abandonment Address 9245 Beatty Drive Suite ;ty sacrament898359 Phone 916-363-9355 j Billable PartyRB Louise LLC, etal AddreSS 1200 Concord Ave city Concord, Chip 94520 Phone 9256748400 GIS Coordinates:x 37.806791 Y -121.288790 Suite 200 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs OELL IDs � 1 i THER IDS TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING I HOLLOW STEM DIA.OF BOREHOLE6 Inch ❑MULTIPLE CASINGS[]MULTI-LEVEL WELL CASING DIA: ©EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC 0 OTHER _ I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 5 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE _❑SOIL BORING O PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —0 INJECTION(i.e.AirSoame.Ozonet❑HAND AUGER GROUT SPECIFICATIONS bentonite - cement surface seal --_❑OTHER: ❑OTHER: APPROX.BORING DEPTH 1P ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: l NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ©EXPLOSIVES FROM TO FT BELOW SURFACE i TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQ PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this appli � 1lh8t tppe ill be done in accordance with San Joaquin County Ordinances,R les and Regulations,and II eplicabl Calf rnia law Q IV T T qY Signed `� itl Company AGE RFc�MFNr �9 PrintName William Little M. 7A7q Date 07/21/15 J� FO. DEPARTM USE ONLYv, 20�$ SITE MAP IN UNIT IV FILE-SITE ADDRESS fR C WORK PLAN DATED APPLICATION ACCEPTED BY �� Oi CA4 DATE ISSUED 7 y AREA 1 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# �� PE CODES FEE INF REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 1173 SR#—.5RC07 RO# (3500) PR# zsoo C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 01!13112 WELL PERMIT APP I i i