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S A N 10 A Q U I N Environmental Health Depn� �s� COUNTY— 14, I SITE MITIGATION WELL & BORING PERMIT APPLICATION 4 For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 38 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 345 Roth Road Citylstatelzip Lathrop, CA 95330 Phone NIA crosd street South Mickinley Ave and Roth Road APN 193-330-30 Propa"Ownsr Beneto Inc. Phone 916-677-0817 Address 4080 Seaport Blvd Cayistateizip West Sacramento, CA 95691 C47 Contractor Cascade Drilling, LP License# 938110 Phone 910-478-0858 Address 120 S. 23rd St. citylstatelzip Richmond, CA 94804 consmtantf5ub-ContractorAhtna Environmental, Inc. License# Nlh Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 citylstatelzip Pleasant Hill, CA 94523 CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite BaringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE C STRU CFICA IONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 14 bgs ❑BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VapaM'aler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2 t0 4 Inch ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER 0 SOILBORING q 0 PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes []No Boring 00: Casing OW: Cadrkg Depth; ❑ INJECTION(Ak sore.om .) ❑ HAND AUGER GROUT SEAL DEPTH Oft bqs TREMIETYPETO BE USED: ❑AUGERS ❑HOSE fa PIPE ❑ OTHER ❑ OTHER: GROUTSEAL PUMPED? 0Yes ❑No (Note:Maximum Freefak Depth is 30 FB WEWSOIL BORING Ice Soli borings 1701 through 1703 GROUTSPECIFICATIONS Neat.non-shrinking-cement grout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth offeet WELL IDs ❑PRESSURE GROUT To depth of_feet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet belay surface or feet below surface if>3 feet COMMENTS: T hereby Certify that 1 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_(IGLv �rwl't� Title/Company Sr. Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG DatuQdO1JerZS7017- aCrV 20y 2017 11 _ DEPARTM�E/NTUB SONLY- Application Accepted By: - i"Tt%� � —Date Issued: , Grout Inspection By/Dates: Destruction Inspection BylDates: Faclillor/Site Information FA Name FA Address FA# C,C U'f Z l PFW '- - FA PE r; C WP Reilewed By Work Plan Date 5 � ZwI " 1 ©Z57 ❑C57AUBwmafionforOthWMBlgn Permit arkers Cann ❑Workers Comp Waver ❑EncroachmentPermil H'Acass ABreemenl 041WAgemyAppiovel QhFR COMMENTSICONDITIONS: kVkmA� �j c., i'�•t -)sd r.� clr2. 1� �.�I *J_ II,,,.',v.'S 1'g S..i.r-�t�LC. WPTYPE PE I SC FEE INFO JANT REMITTED1 CHECK# I RECV'O BY I DATE WELL PERMIT# INVOICE# Penns 3 1 S 31.3 s152x 3 i' 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2M10001-17 Site Mitigation Wes Pardt Application