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:_:,J OAQ U I N Environmental Health Department J COUNTY �" t0 '=�'AITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For INSPECTIONS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. TT' is application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 14290 E.Comstock Road City/State/Zip Linden,CA 95236 Phone (209)351-0124 Cross Street Jack Tone Road APN 091-030-130-000 Property Owri Anderson Bamgrover Ranch Phone (209)351-0124 Address PO Box 127 City/State/Zip Linden,CA 95236 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone (916)759-3512 Address 6821 8th Street City/State/Zip Rio Linda,CA 95673 Consultant/Sub-Contractor Brusca Associates, Inc. License# CEG#1948 Phone (916)677-1470 Address PO Box 332 City/State/Zip Roseville,CA 95661 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See Workplan for monitoring well specifications ❑ MONITORING I ® HOLLOW STEM BORING DEPTH 80 feet ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Surge,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 MW1,MW2,MW3 GROUT SPECIFICATIONS 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 ElPRESSURE 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: 3 groundwater monitoring wells. See provided Workplan and Water Board approval letter 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 )r� ' y ti` Title/Company President, Brusca Associates, Inc. Print Nam oe Brusca Date 2/13/2025 DEPARTMENT USE ONLY Application Accepted By: Date Issued: 3 1 Z Grout Inspection By/Dates: �- - Destruction Inspection By/Dates: r Facili /Site Information FA Name i r��: (1 ( S FA Address /`2�V LO �7� v: FA# v Z �� PR# U FA PE -) ' i> WP Reviewed By Work Plan Date ❑C-57 O c-57 Authorization for Other to Sign Permit [}Workers Comp ❑Worker's omp aiver ❑Encroachment Permit '&LAccess Agreement ❑Lead Agency Approval MFR COMMENTS/CONDITIONS. WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit t -, $152 x } 1 WE '250054- 1 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 04-04-07 Site Mitigation Well Permit Application