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S A N 10 A U I N Environmental Health De �, COUNTY -- Fy` 1 � Cv :rows here. /V Oy 101, y SITE MITIGATION WELL $ BORING PERMIT APPLICATION ryFq<ry For Wells and Borings Used for Contaminant Investigations and Remedlation 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 andlor Install the work described. This application Is made in compliance with San Joaquin County Development Tille,Chapter 9-1115.3, and the San Joaquin County Well Standards, Job Address 250 East Roth Road citylstateizip Lathrop. CA 95330 Phone N/A Gros§street South Mickinley Ave and Roth Road APN 196-030-01 Property owner- Diamond Holdings of California, LLC Phone 209-9834900 Address P.O. Box 156 City/stateizip Meta, MO 65058 C-57 Contractor Cascacre Drilling, LP License# 938110 Phone 910-478-0858 Address 120 S. 23rd St. cityistateop Richmond, CA 94804 ConsultentfSub-Contractor Ahtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 cityistatelzip Pleasant Hill, CA, 94523 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BodngsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE ONSTR C ION SPEC I TIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 140 bcls ❑BOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaporAYater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 t0 4 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: []STEEL ❑PVC ❑ OTHER ® SOILBORING :i=❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes [I No Baring Da: Gazing DX. Casing Depth: ❑ INJECTION IAasnwea omnat ❑ HANDAUGER GROUTSEALDEPTH 4 ft bus TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? ®Yes ❑No (Note:Maximum Freshet Depth Is 30 Fri WEWSOIL BORING IDs Sall borings 1704through 1708 GROUT SPECIFICATIONS Neat, non-shrinking.cement grout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feet WELL IDS ❑PRESSUREGROUT 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 surfacew 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 - an/JooaquinCounty Ordinance Codes and Standards,and all other applicable California laws. Signed yi-- Title/Company Sr. Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG Daterl9etebef PO w 2D/ 2pO DEPARTMENT USEONLY Application Accepted By: r •a Date Issued: 1.1 Vel 1, '1 Grout Inspection BylDates: Destruction Inspection By/Dates: FacilltviSite Information FA Name Lt.' Ark" FAAddress kor, IP—"11� lt! < FA# Oct•t-y t'�.� P FA PE ')yl (s 0 WP Reviewed By I I--_)c Work Plan Date WC-9 ❑C-57AWN(aaationforOlherte Slan PemY1 RWorkers Gaup ❑Workers CompWeiver ❑Encroachment Permit ffAccess Agreement eaaAgencyAppeoval MMFR C yOyMME�tNTSICONDITIONS:�A.• l T.L Pf r�S WP TYPE PE SC I FEE INFO JAMT REmITTED1 CHECK#I RECv'D BY I DATE WELL PERMIT# INVOICE# 9 Permit ylati �t� $152x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 20-010041-17 alb Mlligaaon Well Permit Application (^ SL3 ISz.XS $ '136 a 7`llfS L Y LLf H�1 1 51 oc Ib ' Il