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SAN JOAQUIN Environmental Health Department - - CUUNTY - -- 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 7600 West 11th street City/State/Zip Tracy, CA Phone (925) 548-7910 Cross Street Chrisman Road APN 250 - 150 - 16 Property Owner* Navarra Family LLC Phone (925) 548-7910 Address 475 West Blewett Road City/State/Zip Tracy , CA 95304 C-57 Contractor AdvancedGeo, Inc. License# 1063765 Phone (209) 467-1006 Address 837 Shaw Road City/State/Zip Stockton CA 95215 Consultant/Sub =Contractor AdvancedGeo, Inc. 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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 12 feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 1 .5 inches ❑ MULTIPLE CASINGS ❑ MULTI - LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 2 ® 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 S139 and SB10 GROUT SPECIFICATIONS Portland type II cement to surface grade 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 : 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 C� Title/Company AdvancedGeo, Inc. Print Name Evan Schmidt Date May 6th , 2021 DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued : 5 / 13 /2021 Grout Inspection By/Dates : p1 • SI 2 � Destruction Inspection By/Dates : Facilit /Site Information FAName Navarra Family LLC Properties FAAddress 7500 Eleventh , Tracy FA# FA0026573 pR# PR0546896 FA PE 2950 WP Reviewed By JW 7Work Plan Date 5 /5 / 2021 C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval E:MFR COMMENTS /CONDITIONS . Submit report of finding to EHD ( by mail or to jwong@sjgov . org ) per Well Standards 13 . 7 . 2 WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK# I RECV' D BY I DATE WELL PERMIT# INVOICE# Permit 2905 1 313 1 $ 152 x 2 304 CC JW 5 /6 /2021 WP0042039 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 -3420 F 209 464-0138 1 www . sjcehd . com EHD29-0108-01 -17 Confirmation # : 124963839 SR0083708 Site Mitigation Well Permit Application