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SAN J Environmental Health Department COUNTY — --- - ' �� ' 'f = 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 7590 West 11th street City/State/Zip Tracy , CA Phone (925) 548-7 910 Cross Street Chrisman Road APN 250-150-170-000 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 Cons ultant/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 1 ® 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 S138 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 : 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 AdvancedGeo, Inc. Print Name Evan Schmidt Date May stn , 2021 DEPARTMENT USE ONLY Application Accepted By : /JEFFREY WONG Date Issued : 5 / 13/2021 A Grout Inspection By/ Dates : , 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 Work Plan Date 5 /5/2021 IN C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval 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 REMITTED CHECK# I RECV' D BY DATE WELL PERMIT# INVOICE# Permit 2905 1313 $ 152 x 1 152 CC JW 5 /6 /2021 WP0042038 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 -0138 1 www . sjcehd . com EHD 29-01 08-01 - 17 Confirmation # : 124963839 SR0083708 Site Mitigation Well Permit Application