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N, joi 0H, -a i. �' r Ir J `� o :. E �5.'vl . ' S.i v. , l �.li �a�/v �� I�. G i.� ✓ :. SITE MITIC��TION !/HELL � �®RING PERMIT �►PPLICATI®N For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k8 Hows Advance i1orace Required For A,l Inspections Application is hereby made to San Joaquin County for a permit to construct Al 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, APN 209-060-49 and 209-060-60 Central Job Address Parkway City/State/Zip TRACY, CA 95304 Phone 2na-612.1127 Cross Street West Grant Line Rd. APN 209-060-49 and 209-060-60 Property owner'' Mr. Mike Sandhu 2O9-612-1127 Address 31995 S. Chrisman Rd C-57 Contractor PENECORE DRILLING, INC Address 220 NORTH EAST STREET Consultant/Sub-Contractor TERRACON CONSULTANTS INC Address 902 INDUSTRIAL WAY City/State/Zlp License# City/State/Zip Tracy, CA 95304 WOODLAND, CA 95776 License# 669004 City/StatelZip LODI CA 95240 Phone Phone 530-661-3600 Phone 209-367-3701 CONSTRUOTION WORK TO BE PERFORMED: ''Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING ❑ MONITORIhIG ❑ NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS EXTRACTION (Vapor'Waler) ElSOIL VAPOR PROBE 1'SOIL BORING ❑ INJECTION (AirSpome, ozora) ❑ OTHER WELIISOIL BORING IDs fl HOLLOW STEh1 BORING DEPTH 2n ff ❑BOLTED TRAFFIC BOX ❑STOVE PIPE F1 HAMMMORIVEN DIA, OF BOREHOLE 2 in ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA n MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER 3 44� 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 ❑ HOSE ❑ PIPE n OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freetall Depth is 30 Ft) GROUT SPECIFICATIONS_ NEAT ",FMFN j T ; SURFACE . DESTRUCTION WQRK TO BE PERFQRMED: #WELLS TO BE DESTROYED (YELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE 4E PI COMMENTS: Signed erttfy that 1 am authorized to �o San Joaquin County Ordinance Print Name TONY MIKACICH Destruction Inspection By/D EFFREY WONU DESTRUCTION METHOD: (CHECK ALL THAT APPLYI ❑ OVER -BORE DIAMETER of inches to depth of feet ❑ PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface E MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet his appticetton and- that the warts will be done in accord end Standards, and all other applicable Calliornta taws. Title/Company TERRACON CONSULTANTS INC Date October 22, 2021 DEPARTMENT USE ONLY Application Accepted By: _ Grout Inspection By/Dates; Date Issued: 11/3/2021 Facil(t /Site Information 1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 www.sjcehd.com E"° 29-0' oe-°'-" confirmation #: 133720613 FA Name SANDHU PROPERTY FA Address 20906049 /20906060 FAf� F�10026834 PR# pR05470261 FA PE 2950 WP Reviewed By JW Work Plan Date 10/22/2021 ❑ C•57 %C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workaes Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval MFR COMMENTS/CONDITIONS: Submit a Copy of the sampling results/report to EHD per SJC Well Standards 13.7.2 WP TYPE PE f SC FEE INFO AMT REMITTEDJ CHECK# I RE;CV'D BY I DATE WELL PERMIT# INVOICE# Permit ?905 313 $152 x 3 456 CC I AV 1 10/25/2 WP0042718 SR0084433 Site Mitigation Well Permit Application