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SAN JOAQl11N a Environmental Health Department I? ' � I COUNTY Greatness grows 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/Zip 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 800 511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 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 (Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE ElMULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ElSOIL VAPOR PROBE ElMUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (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: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED 2 ® OVER-BORE DIAMETER of 2 . 0 inches to depth of 20 feet WELL IN W-3 and W-6 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack ❑ 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 : I hereby certify that I am authorized to complete this application and that the work will be done in accordance with pp � � ,,�U,'y'�� , San Joaquin County Ordinance Codes and Standards, and all other applicable California laws . Signed rY"G-- "y„'�' v Title/Company Senior Geologist- AdvancedGeo , Inc. Print Name Brian Millman Date 10/4/2021 DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued : 10/ 12/2021 Grout Inspection By/Dates : Destruction Inspection By/Dates : 71 Facilit /Site Information FA Name PILKINGTON NORTH AMERICA FA Address 500 E LOUISE FA# FA0024170 PR# IR0542090 FA PE 2960 WP Reviewed By I JW Work Plan Date 10/4/2021 [XC-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement E Lead Agency Approval LXMFR COMMENTS/CONDITIONS : WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 1$ 152X 2 304 1 CC I JW 10/5 /21 1 WP0042647 Confirmation # : 132788283 SR0084346 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 1 F 209 464-0138 1 www . sjgov. org/ehd EHD29-01 06-28-21 Site MiUgahon Well Permit Application