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SAN JOAQUIN Environmental Health Department r �. � I COU N T Y � 7 Qf: Greatness grows here . SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON - REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 3 East Eleventh ( 11th ) Street City/State/zip Tracy , California 95304 Phone (209 ) 467 - 1006 Cross Street Holly Drive APN 233-369- 18 Property Owner* Levand Family Trust/ Levand Bright Family Trust - Trustees , Paula Levand & Joan Konkel Phone ( 661 ) 904 -2133 Address 24692 Sand Wedge Lane City/State/Zip Valencia , California C -57 Contractor Penecore Drilling Inc. License# 906899 Phone ( 916 ) 753-5127 Address 220 North East Street City/State/Zip Woodland , California Consultant/Sub -Contractor AGI License# 1063765 Phone ( 209 ) 467 - 1006 Address 837 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 WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA , OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI- LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD 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) WELL/ SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED 4 ® OVER- BORE DIAMETER of 8 inches to depth of 20 feet WELL IDs MW- 1 , MW-2 , MW-3 , and MW-6 ,� PRESSURE GROUT To depth o" ) feet below surface GROUT SPECIFICATIONS Portland Type II and not more than s gallons/94 Ib 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 : ** See attached Work Plan and site plan ** ALL WELLS TO BE OVERDRILLED PER AGREEMENT BY PHONE WITH AGI BRIAN MILLMAN ON 3/29 /21 1 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 Project Geologist Print Name Brian Millman Date 3112 /21 DEPARTMENT USE ONLY Application Accepted By : JEFFREY WONG Date Issued : 3 /29 /2021 Grout Inspection By/Dates : Destruction Inspection By/ Dates : _( Facilit /Site Information FA Name LEVAND BRIGHT WELL DES TFAAddress 3 E . ELEVENTH , TRACY FFA# FA0023981 PR# PR0541817 FA PE 2960 WP Reviewed By JW Work Plan Date 3 / 15/2021 K] C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement C4 Lead Agency Approval MFR COMMENTS/CONDITIONS : SUMBIT REPORT TO EHD PER SJC WELL STANDARDS . 13 . 7 . 2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# I RECV' D BY DATE I WELL PERMIT# INVOICE# Permit 2902 313 $ 152x 4 608 CC JW 3 / 15/2021 WP0041868 1868 E . Hazelton AvenueI Stockton , California 95205 1 T 209 468 - 34201 F 209 464 - 0138 www , sjcehd . com EHD 29-0108-01 -17 Confirmation umber : 122081336 SR0080135 Site Mitigation Well Permit Application