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,' PC1U1ry C <br /> SAN JOA U I N Environmental Health Dep nt <br /> COUNTY *4� 1% <br /> Greatness grows here. Fti I 40 <br /> SITE MITIGATION SRO"�'Fy ??4918 <br /> S TIGA ON WELL & BORING PERMIT APPLICATION ry <br /> For Wells and Borings Used for Contaminant Investigations and Remediation ry <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 250 East Roth Road City/State/Zip Lathrop, CA 95330 Phone N/A <br /> Cross Street N/A APN 196-030-01 <br /> Property Owner* Diamond Holdings of California, LLC Phone 209-983-4900 <br /> Address P.O. Box 156 City/State/Zip Meta, MO 65058 <br /> C-57 Contractor Cascade Drilling, LP License# 938110 Phone 910-478-0858 <br /> Address 120 S. 23rd St. City/State/zip Richmond, CA 94804 <br /> ConsultanVSub-contractor Ahtna Environmental, Inc. License# N/A Phone 916-396-5309 <br /> Address 2255 Contra Costa Blvd, Ste 312 City/State/zip Pleasant Hill, CA 94523 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs EWNA8 ®PRESSURE GROUT To depth of 0 feet below surface <br /> GROUT SPECIFICATIONS Cement bentonite grout ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company Sr. Geologist, Program Manager/Ahtna Environmental, Inc. <br /> Print Name Rachel Kerr, PG Date March 7, 2018 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑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 <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 OM1-17 Site Mitigation Well Permit Application <br />