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SAN JOAQUIN Environmental Health Department - COUNTY— • G,Cotness Qr0s.S 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 Tide,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 12030 Harlan Rd City/State/ZIp _Lathrop,CA 95330 Phone 800-796-9573 Cross Street Harlan and Roth Roads APN 196-030-28 Property Owner* BMG2 Enterprises,LP Phone 949-701-2090 Address 3736 Fallon Rd,#410 City/State/Zip Dublin,CA 94568 C-57 Contractor Yellow Jacket Drilling License# C57-1034407 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State/Zip Rancho Cucamonaa.CA 91730-5743 Consultant/Sub-Contractor Ahtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd,Ste 312 Clty/State/Zip Pleasant Hill, CA 94523 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 145 ft bgs iii]BOLTED TRAFFIC BOX ❑STOVE PIPE ® EXTRACTION(Vapor/Water) 1 ❑ HAMMER/DRIVEN DIA OF BOREHOLE 16 in ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ® MUD ROTARY CASING THICKNESS Sch 80-1.06in TYPE OF CASING: ■STEEL■PVC ❑ OTHER steel screen,PVC blank ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes It No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION*Spans,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 119-122 ft bgs TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE®PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ®Yes❑No (Note:Maximum Freefall Depth is 30 Ft) WELUSOIL BORING IDs EWCC6 —GROUT SPECIFICATIONS-Type II Portland cement w/3lbs of powdered non-beneficiated bentonite w/7 gal water per 94-Ib sack of cement mechanically mixed 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 4>3 feet COMMENTS: I hereby ce hat I am authorized to complete this application and that the work will be done In accordance with an oaqulCount r ina ce Codes and Standards,and all other applicable California laws. Signed C,�,. Title/Company Program Manager/Ahtna Environmental Inc. Print Name Rm**Kerr Date July 12,2019 DEPARTMENT USE ONLY y Application Accepted By: Date Issued: 32� 7 Grout Inspection By/Dates: Destruction Inspection By/Dates: - /17 27' FacIIItv1SIte Information FA Name / � FA Address 0 1 FA# o O 24553 I PR# Q FA PE Z p �7 2 L WP Reviewed By rix t,J ryt t Work Plan Date ❑C-57 ❑G57 Auftrizalim for 011w b Sign Penn it ❑Workers Comp ❑Workers Comp waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS:PA IMC- afrill' y 4w,4;( ypry b y 4*K4; 10 3 /f:?-- WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMITS INVOICE# Permit SO 1 $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 0"1-172 'Lse ryl Site Mitigation Well Permit Application 7� ✓ ��P �� I 0Zy"