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SAN-JOAQUIN <br />rOWS <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />Fov dells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES � YEAR FROM DATE ISSUED <br />iii Hours Advance Malice Required For hili inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 250 East fioih Road <br />Cross Street South Mcicinley Ave and Rath Raad <br />Property OWner* Diamond Holdings of California, LLC <br />Address PO Box 156 <br />C-57 Contractor Yellar� Jacket Drilling <br />Address 9460 Lucas Ranch Road <br />ConsultantlSub-Contractor Ahtna Environmer;tal, Inc. <br />Address 2255 Contra Costa Blvd, Ste 312 <br />City/State/Zip i_atnrop, cA 95330 <br />APN 196-030-01 <br />Clty%Stat@/Zip Meta, MO 65058 <br />C57-1034407 <br />Phone 209-662-0569 <br />PilOtle 209-662-0569 <br />Phone 909-939-11563 <br />Cliy/State/Zip Rancho Cucamonga, CA 91730-5743 <br />Lic@nse# NIA Phone 916-396-5309 <br />Citylstat@/Zlp Pleasant Hill, CA 94523 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite 13orings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF UVELLlBOI21NG NUMBER <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ <br />I] EXTRACTION (VaporAWater) 1 ❑ <br />❑ SOIL VAPOR PROBE Q <br />❑ SOIL BORING ❑ <br />E]INJECTION (Air Snarge.Ozone) ❑ <br />1771OTHER ❑ <br />'WELD SOIL BORING IDs EwNC7 <br />HOLLOIV STEM BORING DEPTH 15o r, ®BOLTED TRAFFIC BOX ❑STOVE PIPE <br />HAMMEPJDRIVEN DIA, OF BOREHOLE 18 in ® MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DW <br />MUD ROTARY CASING THICKNESS 3ch 80 -1.06 in TYPE OF CASING: 9 STEEL I] PVC ElOTHER steel screen, PVC blank 8 in casin <br />PUSH POINT (GP/ CPT) CONDUCTOR CASING [IYes M No Boring Dia: Casing Dia: Casing Depth: <br />HAND AUGER GROUT SEAL DEPTH X4-�TXeX TREMIE TYPE TO BE USED: [IAUGERS ElHOSE ® PIPE <br />OTHER: GROUT SEAL PUMPED? Q Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Type it Portland cement w13 lbs of powdered non -beneficiated bentonite w17 gat water per 94 -Ib sac of cement, <br />mechanicall124 8110/21 <br />y mixed <br />Sanitary seal dept 1 to sur ace (Revised <br />DESTRUCTION WORK TO BE PERFORMED: <br />#WELLS TO BE DESTROYED Nene <br />UJELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED (-1 AUGERS 1-1 HOSE 1—I PIPE <br />Z01i4-11lf14 <br />per reques roan ace en' <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER -BORE DIAMETER of W inches to depth of feet <br />❑ PRESSURE GROUT To depth of feet below surface <br />❑ EXPLOSIVES From to feet below surface <br />ElMUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />1 hereby ceri{fy that I am ;authorized to cor>nplete this application and that the work wi116e done in accordance with <br />� ,San J�oaquin�Ct�unty Ordinance Codes and Standards, and all. oth@r applicable California laws. <br />Signed ____ <br />Print Name Ra el Kerr <br />Application Accepted 8y: <br />Grout Inspection BylDates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />JEFFREY WONG <br />Title/Company Ahtna Environmental, Ina! Sr. Program Manager, Geologist <br />Date <br />DEPARTMENT USE ONLY <br />Date Issued: <br />8/ 10/2021 <br />FA Name <br />Sharpe Army Depot, Extraction <br />Wel I <br />FA Address <br />00 <br />ROTH RD, LATHROP <br />FA# <br />FA0024553 <br />PR# <br />PR0542675 <br />FA PE <br />2954 <br />WP Reviewed By <br />JW! <br />Work Plan <br />Date <br />October 2020 <br />ElC-57E] <br />C-57 Authorization for Other to Sign <br />Permit <br />❑ Worker's Comp ElWorker's <br />Comp Waiver 171Encroachment Permit <br />ElAccess Agreement <br />[ILead <br />Agency Approval Q MFR <br />COMMENTSICONDITIONS: Reconunend <br />well <br />position be GPS <br />for fixture locating <br />WP TYPE <br />PE <br />SC <br />I FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL <br />PERMIT# <br />INVOICE# <br />Permit <br />2901 <br />1 313 <br />1$152 x <br />1 <br />1 152 <br />1 cc <br />JW <br />8/10/21 <br />WP0042410 <br />1868 E. Hazelton Avenue � Stockton, California 91205 � i 209 468-3420 � F 209 464-0138 1 wwv,,.sjcehd.cotrl <br />EHD 29-01 08-01-17 confirmation # 129833375 SR0084051 Site Mitigation Well Permit Application <br />