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SAN ,JOAQUIN Environmental Health Department i' —COUNTY— :,,�� Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRED 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. 2460 Toste Rd city/statelZip Tracy, CA, 25377 Phone Job Address APN .286=060=037' Z�� 3 Cross Street Grant Line Rd 946-7523 LEWIS MANAGEMENT CORP. Phone I909) Property owner' Upland,California 91786 Address 1156 North Mountain Avenue cltylstatelZip p 425 527-9830 C•57 Contractor Cascade Drilling License# 938110 Phone (. ) P 0 BOX 1184 cltylstatelZip Woodinville.WA 98072 Address 949 286-0977 Avocet Environmental,Inc. License# 838470 Phone ) Consultant/Sub-Contractor Irvine,CA,92618 Address 1 Technology Drive,Suite C515 CitylStatelZlp CONSTRUCTION WORK TO BE PERFORMED:'Note: ONsfle BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE C_0R &U( ION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 5.5 ft. ❑BOLTED TRAFFIC BOX [I STOVE PIPE ❑ EXTRACTION(VaporN781e0 ❑ HAMMERWMN DIA.OF BOREHOLE 3.6' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA PE OF❑ SOILBORIGPROBE 3 0 MUD PUSHROTARY ICPT) CASCOINGTHIRCASINGCKNESS /8 Ty ❑Yes❑No Bodngga CASING: Cring Ny Rbo9�tubing ❑ INJECTION(Ak Smm 0 1 IO HAND AUGER win GROUT GROUT SEAL DEPTH ❑Yes❑No TREMIIE TYfi O BE B USED, 3 A�1FGIERS❑HOSE❑PIPE ❑ OTHER 19I OTHER J, Ir �e h1 Q.t/17i- WEWSOILBONNGIDs SV-1 through SV-3 GROUT SPECIFICATIONS nJN21 `'� DESTRUCTION WORK TO BE PERFORMED_: DESTRUCTION METHOD,ICHECK ALL THAT APPLYI Ly #WELLS TO BE DESTROYED OVER-BORE DIAMETER of_inches to depth of feet WELL IDS ❑PRESSURE GROUT To depth of_feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3feet bebw surface or feet belay 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 an Joaquin county Ordinance Codes and Standards,and all other applicable California laws. Title/Company Protect Engineer,Avocet Environmental Inc. Print Name Darren Brandner Date 02/O6I2020 PAR TNIENT USEONLY �la/Z�Zy Date Issued: _1 L Application Accepted By: Grout Inspection By/Dales: �— Destruction Inspection By/Dales: 3 2.02-0 Facilil /Site Information oO h PR# [` FA Name � —� i� �I FA Address 6Q '�S-�' FA# 7 O J��r ZR WP Reviewed ,( - ] Wark Plan Date ( � 1 ZD FA PE J W ❑O57 C-57 Authorization for Oter b S hign Permit ❑Workers comp ❑Wohsrslccwvwal'rer DEncroachnenlPermll ❑Ac=Agreement ❑Le`d AgagAWowl ❑MFR III COMMENTSI ITIONS: 51Ab(41. I l:a'Ty ' 'nnCa 06t6i>rwllov's Cam* I Wcus Voidudl sad was ktt b ERM INVOICE# WP TYPE �r qPE SC FEE INFO AMT REMITTED C'HI,E�C}K# RECV'D BY DATE POO 06 Permll 7/1(�' 313 5152 x ( - IIns Z eo 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-3420 i F 209 464 omjug �N 1��iba m EHD 29,010&01-17