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SAN JOAQUIN Environmental Health Department �T' -- COUNTY 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 Address1151 North Holly Drive City/State/Zip Tracy , California 95304 Phone ( 209 ) 467 - 1006 Cross Street East 11th Street APN 233 - 120 - 150 Property Owner* Denzel Thompson Phone (209 ) 467 - 1006 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 ❑ SOIL VAPOR PROBE ❑ 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 1 ® OVER- BORE DIAMETER of 8 inches to depth of 20 feet WELL IDs MW-5 ❑ PRESSURE GROUT To depth of 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 ** 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 Title/Company Project Geologist Print Name Brian Millman Date 3/ 12 /21 DEPARTMENT USE ONLY Application Accepted By : JEFFREY WONG Date Issued : 3/29/2021 Grout Inspection By/Dates : Destruction Inspection By/Dates : 49 Z� Facilit /Site Information FAName LEVAND BRIGHT WELL DES FAAddress 3 E . ELEVENTH , TRACY FA# FA0023981 PR# PR0541817 FA PE 2960 WP Reviewed By JW Work Plan Date 3 / 15 /2021 J4I C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ? Access Agreement LN Lead Agency Approval IN MFR COMMENTS/CONDITIONS . SUMBIT REPORT TO EHD PER SJC WELL STANDARDS . 13 . 7 . 2 . ACCESS AGREEMENT ON FILE WP TYPE PE I SC I FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 1$ 152 x 1 152 CC JW 3 / 15 /2021 1 WP0041870 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 1 F 209 464 - 0138 1 www . sjcehd . com EHD29-0108-01 - 17 Confirmation Number : 122081336 SR0080135 Site Mitigation Well Permit Application