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RECEIVED SAN JOAQUIN COUNTY FEB 0 6 2013 ?�+ ENVIRONMENTAL HEALTH DEPARTMENT U"NVIltOVMEN'"1AL 11FAL,1-11 1868 Hazelton Avenue, Stockton, CA 95205-6232 li I'.I : RTN 1 F.N'1' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.secehd.com \Cha Rte% SITE MITIGATION 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 San Joaquin County Well Standards. Job Address 2325 West Louise Ave City/State/Zip Manteca/CA/95337 Phone Cross street South Airport Way APN 198-110-14 Property Owner* Exeter Louise Land, LLC - Eric Deo Phone 510-398-9956 Address 2001Broadway, Suite 150 city/state/zip Oakland/CA/94612 C-57 Contractor PeneCore Drilling, Inc. License# 906899 Phone 530-661-3600 Address 220 N East Street City/State/Zip Woodland, CA 95776 Consultant/Sub-Contractor Nova Consulting Group, Inc. License# Phone 480-261-1355 Address 1107 Hazeltine Blvd. #400 City/State/zip Chaska/MN/55318 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ,,t ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N SOIL BORING 12,_l9 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 'IPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. ,q Signed C 4%�L _ Title/Company PAW e Dr'A Print Name 101 Ttl Ani N_,_T� Date 1 1 1 S6 1 jig DEPARTMENT USE ONLY Application Accepted By: Date Issued: 2-220 jr Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name /cyw' � � FA Address ��J �u�_, FA# ��1 6 X PR# FA PE �V'71 �fly WP sewed By Work Plan Date El C-57 ❑C-5 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval R C�yO�M�MENTLS/CO`N-DITIIOONS: �_ n �y� S YX Cp�yti.� Cy . _•�JL ��-f ✓�'(�1�!-� r �(JvLki(/ W¢tel � Tj �' '� tnrCh��. (�M`J SR TYPE PE sC FEE INFO AMT REMITTED CHECK# RECV'D BY 15ATE SERVICE REQUEST# OICE# Permit w),f �7aX39 x /0 ZZ/ Y.0 P.UO T/ 6 V4 0X03 1 � S-� f� �-� ��, oz� 7 K'7 S� EHD 29-01 10-26-2015 Site Mitigation Well Permit Application