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SAN I J O A Q U IN Environmental Health Department - COUNTY Greatness gra ,ls here , SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL ( 209 ) 953 =7697 For 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 980 East Louise Avenue City/State/Zip Lathrop, CA, 95330 Phone 925-674-8400 Cross Street Harlan Road APN 198-120-110 Property Owner* ASP/RWM Properties LLC, R&B Louise and Delta LLC Phone 925-674-8400 Address 1200 Concord Avenue Suite 200 City/State/Z( p Concord , CA, 94520 C-57 Contractor Cascade Environmental License# 1058336 Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip West Sacramento CA 95691 Consultant/Sub-Contractor AdvancedGeo , Inc. License# 1063765 Phone 8005111 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 CONSTRUCTION WORK TO BE PERFORMED : 'Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING HOLLOW STEM BORING DEPTH 15 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (VaporMaler) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 8 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER SOILBORING —�❑ PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring D(a: Casing Dia: Casing Depth: ❑ INJECTION (Air soxaeozone) ❑ HANDAUGER GROUTSEALDEPTH 15 feet TREMIE TYPE TO BE USED: ® AUGERS El HOSE El PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes El No (Note: Maximum Freefall Depth Is 30 Ft) WELUSOIL BORING IDs GROUT SPECIFICATIONS Portland Cement 6Igp Inns Per qd the cork IV/ 1 ,4 ( OIL r DESTRUCTION WORK TO BE PERFORMED : I � D STRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ` �"~ i OVER-BORE DIAMETER of , inches to depth of _ feet WELL IN J P ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS 1PIN 12,621EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED I AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS : 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 Senior Geologist- AdvancedGeo , Inc. Print Name Brian Millman Date 10/4/2021 DEPARTMENT USE 014LY r Application Accepted By: JEFFREY WONG Date Issued : �® Q/o/i Grout Inspection By/Dates : Destruction Inspection By/Dates Facillt /Site Information FA Name PILKINGTON NORTH AlvfERICA FA Address 500 E LOUISE FA# FA0024170 PR# PR0542090 FA PE 2960 WP Reviewed By JW Work Plan Date 10/4/2021 [XC-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Workers Comp Waiver [] Encroachment Permit ❑ Access Agreement [Read Agency Approval [XMFR COMMENTS/CONDITIONS : WP TYPE PE 1 -- SC - - FEE- INFO - - - AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# — Permit Z`lD 313 $ 152 x 2 304 CC I JW 1 i 9AZ49d WP00 0q Confimiation # : 13 : 2 -4Z7 SR0084346 1868 E . Hazelton AvenGe I Rockton , California 952051 T 209 468-3420 1 F 209 464 -0138 1 www, sjgov. org/ehd EHD 29-0106-28-21 Site Mlllgallon Well Permit Application