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SAN ) Q A Q U N Environmental Health Department COIJNTY- CJI is Jin.:,5 �I v4r, .cr _. 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 23701 South Santa Fe Road City/State/Zip Riverbank/CA/95367 Phone (209) 550-1154 Cross Street Henry Road APN 249-060-120 Property Owner* Brilliant Nest Inc Phone Address 23565 S. Santa Fe City/State/Zip Riverbank/CA195320 C-57 Contractor V&W Drilling License# C57 #720904 Phone Address 1133 Blackhurst Drive City/State/Zip Galt/CA/95632 Consultant/Sub-Contractor Condor Earth License# PG #9945 Phone (209) 513-7634 Address 188 Frank West Circle, Suite I City/State/Zip Stockton/CA195206 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (VaporNValer) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air SDdfne, Ozone l ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ 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 1 ❑ OVER -BORE DIAMETER of inches to depth of feet WELL 11; MW -8 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat Cement [ EXPLOSIVES From 26 to 40 feet below surface TREMIE TYPE TO BE USED ❑ AUGERS [-]HOSE ❑x PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feel COMMENTS: Explosives will be placed below the sanitary seal to depth. Detenalion by Tylor McMillian Cert of Eligibility Bureau of Firearms #13854 I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Prdinance Codes and Standards, and all other applicable California laws. Signed �� - Title/Company Condor Earth Geologist 9 Print Name Luke Castle Dale /Z) Application Accepted By: Grout Inspection By/Date Destruction Inspection By/Dates: Date Issued: 10 // 9./ z° Z FA Name AR & //� Address Z 3 J �" FA# O O 253 PR# O FA PE �7 WP Reviewed By `! Work Plan Date / P12 ❑ C-57 -57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workers Camp Waiver ❑ Encroachment Permit ccess Agreement Lead Agency Approval MFR COMMENTS/C N (TIONS: WP TYPE I PE I SC FEE INFO JAMT REMITTED1 CHECK# I RECV-D BY I DATE WELL PERMIT# INVOICE# Permit31 152 x ? C 11, Ze2 Ul Too 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3120 1 F 209 464-0138 1 www.sjcehd.com EHD 29-07 08-01-17 r �( �, a lir M 5-3/ �� 3') Site Mitigation Well Permit Application