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SAN JOAQUIN ----- c o u N T Y-- SITE MITIGATION WELL Ot 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 andlor 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 689 Industrial Park Drive City/StatelZip Manteca CA 95337 Phone J408)-954-1000 cross street Bessemer Avenue APN 221-190-570 Property Owner' Irene Pestana Trust ETAL Phone (209) 612-5573 Address 84 West Santa Clara Street City/State/Zip San Jose, CA 95133 C-57 Contractor Slagle Drilling.Corp. License# 1046151 Phone (916) -363-9355 Address 11345 Trade Center Drive Suite 450 CitylStatelZip Rancho Cordova, CA 95742 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone Address 837 Shaw Road City/State/Zip Rancho Cordova, CA 95742 (209) 467-1006 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ❑ MONITORING ❑ ❑ EXTRACTION (Vapor/V4ater) ❑ ❑ SOIL VAPOR PROBE ❑ ❑ SOIL BORING ❑ El INJECTION fAk Soxne ozonol ❑ El OTHER ❑ WELL/ SOIL BORING IDs INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMER/DRIVEN DIA. OF BOREHOLE ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC El OTHER PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS E] HOSE ❑ PIPE OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) [:]Access Agreement [ILead GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: fchlEOt<ALLTHATAPPLY) 37' BSG MIN # WELLS TO BE DESTROYED One (1) ® OVER -BORE DIAMETER of 8.25 inches to depth of TD feet WELL IDs Mw -1 [:1PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland type II cement to surface grade ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ElHOSE ® PIPE ElMUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS: certify that I am authorized to complete this application and that the work will be done in accord San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Title/Company SB.KtUf C'7volr,i T�41r� Print Name �� U i\�U4^& Ly Date JEFFREY WONN- �� • Z - DEPARTMENT USE ONLY 116 Application Accepted By: Grout Inspection BylDafes: Destruction Inspection By/Dates: G Date Issued: ii��i7iP�7,i FA Name 1868 E. Hazelton Avenue � Stockton. California 95205 � T 209 468-3420 � F 209 464-0138 1 vwvw.sjcehd.com FHn g4nl ne-0i_17 Site Mitigation VACANT L,Q"T FA Address 6g9 INDUSTRIAL PARI FA# 26497 PR# 5466$2 FA PE 2960 WP Reviewed By JW Work Plan Date 4/14/2021 [\qC,57 ❑ G57 Authorization COMMENTS/CONDITIONS: for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver [:]Encroachment Permit Submit report to EHD per SJC Well Standards [:]Access Agreement [ILead Agency Approval qNFR WP TYPE PE SC I FEE INFO JAMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 $152X 1 152 �'� J�iti' 4/13/21 WP0041937 Well Permit Application CONFIRMATION # 123755737 SR0083568