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REcEft p W ftc �P C erl"' SAN�JOAQUIN eN�, �M� fental Healthr�gi p;/artment COUNTY— Greatness OUNTY Greatness grows here. r1.4, �, c 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 250 East Roth Road City/State/Zip Lathrop, CA 95330 Phone N/A Cross Street N/A APN 196-030-01 Property Owner* Diamond Holdings of California, LLC Phone 209-983-4900 Address P.O. Box 156 City/State/Zip Meta, MO 65058 C-57 Contractor Gregory Drilling, Inc. License# 1007649 Phone 425-869-2372 Address 17609 NE 70th St. City/State/zip Redmond, WA 98052 Consultant/Sub-contractorAhtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 City/State/Zip Pleasant Hill, CA 94523 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) ❑ HAMMERIDRIVEN 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 Souge.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 44f'3"inches to depth of 35 feet WELL IDs EWNA8 ❑PRESSURE GROUT To depth of 0 feet below surface GROUT SPECIFICATIONS Cement bentonite grout ❑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 Sr. Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG Date February28, 2019 PARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: j4 LA .-APO r Facilit /Site Information FA Name �{P �� -1 �- FA Address "1 V J �44f " FA# 00 Zy SS3 PR# o.-y Z(� � FA PE Z�(o S WP Reviewed By L -)( Work Plan Date 3 q I t 57 ❑C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ead Agency ApprovalMFR COMM ENTS/CONDITIONS:—�OfM nUSsQ. Gv� S1.w�� `o vn r.a�t v�urt.. '1v. �S°10 WP TYPE I PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# Permit 313 $152 x 1 4 t SL i;'-3r4 L--x We003yg8s- 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application