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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com 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 1120 Holly Drive City/State/Zip Tracy, CA, 95376 Phone (800) 511-9300 Cross Street East 11th Street APN 233-369-19 Property Owner* Levand Family Trust/Levand Bright Family Trust- Trustees, Paula Levand & Joan Konkel Phone (661) 904-2133 Address 24692 Sand Wedge Lane City/State/Zip Valencia, CA, 91355 C-57 Contractor Advanced GeoEnvironmental, Inc (AGE) License# 680227 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 Consultant/Sub-Contractor AGE License# 680227 Address 837 Shaw Road City/State/Zip Stockton, CA, 95215 Phone (800) 511-9300 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING MONITORING El EXTRACTION (Vapor/Water) SOIL VAPOR PROBE 12 SOIL BORING INJECTION (Air Spam. Ozonel NUMBER INSTALLATION TYPE 0 HOLLOW STEM 0 HAMMER/DRIVEN 0 MUD ROTARY 2 D3 PUSH POINT (GP/ CPT) 0 HAND AUGER 0 BOLTED TRAFFIC BOX 0 STOVE PIPE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA NA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER Boring Dip: NA Casing Din: NA Casing Depth NA TREMIE TYPE TO BE USED: El AUGERS 0 HOSE 3 PIPE CONSTRUCTION SPECIFICATIONS BORING DEPTH 20-40' DIA. OF BOREHOLE 1.5" CASING THICKNESS CONDUCTOR CASING 0 Yes 3 No GROUT SEAL DEPTH DOTHER 0OTHER: WELL/ SOIL BORING IDs 6 , $" GROUT SPECIFICATIONS Potland Type I/11 5-6 gallons water per 94Ib GROUT SEAL PUMPED? 0 Yes III No (Note: Maximum Freefall Depth is 30 Ft) DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED D AUGERS El HOSE [1 PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) LI OVER-BORE DIAMETER of El PRESSURE GROUT To depth of LI EXPLOSIVES From LI MUSHROOM CAP El 3 feet below surface or to inches to depth of feet feet below surface feet below surface feet below surface if >3 feet COMMENTS: See Preliminary Site Assessment Work Plan, dated 02 January 2015 and CVRWOCB Approval letter dated 29 July 2016 (GeoTracker). I hereby certify that I am authorized to complete this application and that the work will be done in accordance with Sandbaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Title/Company Project Geologist / AGE Print Name Brian Millman Date 19 April 2017 DEPARTMENT USE ONLY Application Accepted By: Date Issued: '7 / Grout Inspection By/Dates: 6 6 Destruction Inspection By/Dates: Facility/Site Information FA Name - e v':- —11 1 (ut.,)1 FA Address lw- ,i , - ,.__ FA# t_ ,- 3 ri II PR# FA PE -Z 17' 6 -0 WP Reviewed By . - Work Plan Date / ( 7 .-) / /1 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. El Lead Agency Approval 0 MFR COMMENTS/CONDITIONS: , , ii,j4q-C -4 AN,-...,4) (. p eit\P-JL i c iiti .4.12- '`* 7/z1( / i •44. SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit ,'(-, :----'1 i $139 x • 7-- 1 7 Y 2.:_s•s- _,,t,4-- )7/ 4-:: -7 00 7 .7 10 Site Mitigation Well Permit Application EHD 29-01 10-26-2015