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SAN J Environmental Health Department u COUNTY - +�9z ' . 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 204 Vasconcellos Avenue City/State/Zip Manteca , CA 95336 Phone Cross Street State Route 120 APN 22802051 Property Owner* David Tenney Phone 209-993-0624 Address 204 Vasconcellos Avenue City/State/Zip Manteca , CA 95336 C -57 Contractor Cascade Drilling License# 1058336 Phone 510-478-0858 Address 3459 Collins Avenue City/State/Zip Richmond, CA 94806 Consultant/Sub -Contractor Fulcrum Resources Environmental License# Phone 916-479-0859 Address 415 W. Chestnut Avenue City/State/Zip Monrovia, CA 91016 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 25 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA , OF BOREHOLE 2.25" ❑ MULTIPLE CASINGS ❑ MULTI- LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 4 V 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) WELL/ SOIL BORING IDs SB1 , SB2 , SB3 , SB4 GROUT SPECIFICATIONS standard ratio grout to water Nea CewA DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ 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 San Joaquin County Ordinance Codes and Standards , and all other applicable California laws . Signed 4e= YL — Title/Company Geologist, Fulcrum Resources Environmental Print Name Forest Kan Date March 30, 2022 JIDEPARTMENT USE ONLY Application Accepted By : �4& Date Issued : �� • 2 Grout Inspection By/ Dates : Destruction Inspection By/ Dates : Facilit /Site Information FA NameL) l c ru 2 2So t�rCeS FA Address ZQ LO Vks � e FA# Q �' ® C( � PR# 0 54 46 62. FA PE2 `5 0 WP Reviewed By Work Plan Date 3St 57 C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval �MFJR,, PL OMMENTS/CONDI ONS - Pro � C#*� C 0 fir 5&vyW%C I , S � t�s � r +0 C� I S } J 2 WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# I RECV' D BY I DATE I WELL PERMIT# INVOICE# PermitZ90 313 $ 152x 3 L 5 Cc I :SW `f ZZ VJP 0 01 #5k Coy, ; rdv� aM 41 14 1 6 8Z Sfz 00g 10 � 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 1 www . sjgov . org /ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application