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SAN JOAQUIN <br />COUNTY <br /> Environmental Hea4 Department <br />SITE MITIGATION WELL & BORING PERMIT APPLicedia/ / 20v <br />For Wells and Borings Used for Contaminant Investigations and <br />7 <br />Re#4,0* <br />Rmi - _ <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 Murphy Parkway <br /> City/State/Zip Lathrop, Ca <br />Properly owner*R&B Louise, LLC et al (attn: Dana Parry) <br />Address c/o Reynolds and Brown, 1200 Concord Ave, Suite 200 City/State/Zip Concord, Ca 94520 <br />C-57 Contractor Cascade Drilling L.P. License# 93 8 1 10 <br />Address 120 S. 23rd Street <br />City/State/Zip Richmond, Ca 94804 <br />License# <br />Phone <br />Phone (925) 674-8400 <br />Phone (510) 478-0858 <br />Phone (916) 865-3135 <br />Cross Street D'Arcy Parkway APN 198-379-3834 <br />ConsultantISub-Contractor ArCadiS IJ.S. Inc <br />Address 101 Creekside Ridge Court, Suite 200 City/State/Zip Roseville, Ca 95678 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA, OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <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 ID AUGERS D HOSE RI PIPE <br />COMMENTS: <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-BORE DIAMETER of inches to depth of feet <br />NI PRESSURE GROUT To depth of 218 feet below surface <br />I:EXPLOSIVES From to feet below surface <br />IN MUSHROOM CAP ffil 3 feet below surface or feet below surface if >3 feet <br /> <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 /> Title/Company <br />Date <br /> <br />Signed <br />Print Name <br /> <br />DEPARTMENT USE ONLY <br />Date Issued: <br />Application Accepted By: <br />TYPE OF WELL/BORING NUMBER <br />MONITORING 0 <br />EXTRACTION (Vapor/Water) 0 <br />SOIL VAPOR PROBE 0 <br />SOIL BORING 0 <br />INJECTION (Air SDNC10. °zonal 0 <br />OTHER 0 <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: Maximum FreefaIl Depth is 30 Ft) <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />FA Name <br />FA PE <br />0 c-57 <br />0 C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />FA Address 1 <br />WP Reviewed By 1 <br />I Work Plan Date I <br />I FA# 1 PR# <br />COMMENTS/CONDITIONS: <br />WP TYPE PE <br />\Permit <br />1888 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 <br />Site Mitigation Well Permit Application <br />SC <br />$152 x <br />FEE INFO AMT REMITTED CHECK# RECV'D BY DATE <br />WELL PERMIT# <br />INVOICE#