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SAN JOAQUIN <br />COUNTY <br />Greotness grows here <br />Environmental Health Department <br />Murphy Parkway City/State/Zip Lathrop, Ca Phone <br />APN 198-379-3834 <br />Job Address <br />Cross Street D'Arcy Parkway <br />I. • <br />4 <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 />Property Owner*R&B Louise, LLC eta! (attn: Dana Parry) <br /> <br />Phone (925) 674-8400 <br /> <br />Address c/o Reynolds and Brown, 1200 Concord Ave, Suite 200 <br />C-57 contractor Cascade Drilling L.P. <br />Address 120 S. 23rd Street <br />Consultant/Sub-Contractor Arcadis U.S. Inc <br />Address 101 Creekside Ridge Court, Suite 200 <br />city/stateizip Concord,,Ca 94520 <br />License# 938110 Phone (510) 478-0858 <br />City/State/Zip Richmond. Ca 94804 <br />License# Phone (916) 865-3135 <br />City/State/Zip Roseville, Ca 95678 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Re-que Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIO , V <br />CI MONITORING 0 HOLLOW STEM BORING DEPTH 0 BOL D TRAFFIC BOX 0 STOVE PIPE <br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 0 MUt E CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS .k TYPEflC ING: 0 STEEL 0 PVC 0 OTHER <br />SOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes <br />INJECTION (Air Sparse. Ozonel 0 HAND AUGER GROUT SEAL DEPTH <br />OTHER 0 OTHER: GROUT SEAL PUMPED? <br />GROUT SPECIFICATI <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED Six <br />WELL IDs EW-04, EW-04A, INJ-14, PW08-076, PW08-155, PW08-180 <br />GROUT SPECIFICATIONS Neat cement grout <br />TREMIE TYPE TO BE USED El AUGERS 0 HOSE NI PIPE <br />COMMENTS: <br />I hereby certify that I am authorized to comiete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance odes and Standards, and all other applicable California laws. <br />Title/Company <br />Print Name Date <br /> <br />DEPARTMENT USE ONLY <br />Application Accepted By: Date Issued: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />• . racaa /bite <br />FA Name <br />inrormauon <br />/ FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />WELU SOIL BORING IDs <br />OVER-BOR <br />PRESSURE ROUT <br />0 EXPLOSIVES <br />ai MUSHROOM CAP <br />• <br />AlW <br />TRUC • <br />No Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TY TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />ate: Maximum Freefall Depth is 30 Ft) <br />N METHOD: (CHECK ALL THAT APPLY). <br />DIAMETER of inches to depth of feet <br />To depth of 218 feet below surface <br />From to feet below surface <br />NI 3 feet below surface or feet below surface if >3 feet <br />Signed