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SA N��10 A Q U I N Environmental Health Department COUNTY Greorness grows here. 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 48 Hours Advance Notice Required For All Inspections 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 1909 E Louise Ave City/State/Zip Lathrop/CA/95330 Phone 209-858-4125 Cross Street McKinley Rd APN 198100100000 Property Owner* 342 Sycanda LLC Phone 209-858-4125 Address 3515 Yosemite Ave City/State/Zip Lathrop/CA/95330 C-57 Contractor Yellow Jacket Drilling Service,LLC License# 1034407 11 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State/Zip Rancho Cucamonga,CA 91730 Consultant/Sub-Contractor Geosyntec Consultants,Inc. License# Phone 916-637-8334 Address 3043 Gold Canal Dr. City/State/Zip Rancho Cordova,.CA 95670 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER MSTALLATION TYPE CONSTRUCTION SPECIFICATIONS [29 MONITORING 1 ❑ H LLOW STEM BORING DEPTH Up to 300 ft bgs ❑BOLTED TRAFFIC BOX [/9 STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD R6WY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ElSOIL BORING ❑ PUSH POI (GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ©PIPE ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs PW-39 GROUT SPECIFICATIONS Type II-V 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 monitoring well will be installed to a maximum depth of 300 ft bgs. See attached table with well specifications. I 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. Signed Title/Company Professional/Geosyntec Consultants,Inc. Print Name Garrett Thornton Date November 1,2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: !/ Destruction Inspection By/Dates: Facilit /Site Information FA Name Sy FA Address `y J�, FA# 1(9PR# FA PE 0 WP Reviewed By Work Plan Date ❑C-57 57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit Access Agreement IeLead Agency Approval MFR COMMENTS/CONDITIONS: WP TYPE PE SC I FEE INFO JAMT REMITTEDI CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com EHD 29-0108-01-17 Site Mitigation Well Permit Applicatlon