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c �- SAN JOAQUIN Environmental Health Department r`Q ` i , COUNTY , Foa , 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 1120 North Holly Drive City/State/Zip Tracy , California 95304 Phone (209 ) 467 - 1006 Cross Street East 11th Street APN 233-369 - 19 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 ❑ 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-4 ❑ 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 LN 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 DEST FA Address 3 E . ELEVENTH , TRACY FA# FA0023981 PR# PR0541817 FA PE 2960 WP Reviewed By JW Work Plan Date 3 / 15 /2021 P C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement [A Lead Agency Approval [XMFR COMMENTS/CONDITIONS : SUMBIT REPORT TO EHD PER SJC WELL STANDARDS . 13 . 7 . 2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 $ 152 x 1 152 CC jW 3 / 15/2021 WP0041869 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 1 www . sjcehd . com EHD29-01 08-01 - 17 Confirmation Number : 122081336 SR0080135 Site Mitigation Well Permit Application