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SAN )OAQ U I N Environmental Health Department -COUNTY 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 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 Gregg Drilling &Testing License# 485165 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-contractor Ahtna 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 BoringsNVells 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) ❑ HAMMER/DRIVEN 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(Ah Soame.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) WELU 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 15 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 7�u K- Title/Company Sr. Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG Date June 25, 2018 DEPARTMENT USE ONLY Application Accepted By: Date Issued: k10 7l X Grout Inspection By/Dates: Destruction Inspection By/Dates: f Facilit /Site Information FA NameS VL,, -( (�'vw1.� ` k-f- FA Address ��_ t� ( 1 FA# jt)J(� PR# C"`Zr Z_'C_- FA PE i E] z�sl /Z-q s-q i WP Reviewed By L Work Plan Date 31 jj ler ❑C-57 C-57 Authorization for Other to Sign Permit orkers Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agreement ad Agency Approval grlrFR COMMENTS/CONDITIONS: �ti� vt/}Y� fl w Stiw,U Ct•^ ,,n ,• / `^mac "e-- 3 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# IN OI Permit -240 Z_, �I $152 x 4 k1371 1__ v`j P0�7384&� 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 0e-01-17 Site Mitigation Well Permit Application