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SAN JOAQUIN l Environmental Health De ment c " 11+ COUNTY tftO \�cq J oa��r' Greatness grows here. O`C SITE MITIGATION WELL & BORING PERMIT APPLICATIC tmc' H �8 For Wells and Borings Used for Contaminant Investigations and RemediatlonEiVr�lry 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 345 Roth Road City/State/Zip Lathrop, CA 95330 Phone N/A cross street South Mickinley Ave and Roth Road APN 193-330-30 Property Owner* Beneto Inc. Phone 916-677-0817 Address 4080 Seaport Blvd City/State/Zip West Sacramento, CA 95691 C-57 Contractor Yellow Jacket Drilling License# C57-1034407 Phone 909-989-8563 Address 9460 Lucas Ranch Road City/State/Zip Rancho Cucamonga, CA 91730-5743 Consultant/sub-ContractorAhtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 CitylState/Zip Pleasant Hill, CA 94523 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 140 ft bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA,OF BOREHOLE 6 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 3 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUTSEAL DEPTH Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? ❑Yes []No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs Soil borings 1701, 1702,and 1703 GROUT SPECIFICATIONS Neat,non-shrinking cement grout 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 ❑PRESSURE 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: 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 « -- Title/Company Sr.Geologist, Program Manager/Ahtna Environmental, Inc. Print Name Rachel Kerr, PG Date December 18, 2018 EPARTMENT USE ONLY Application Accepted By: � Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name 5i i�+✓p 0q,•t FA Address (.c°�` FA# v 0, L(Z,-73 PR# USL1 ZZ79 FA PE �-�I_�1 _i WP Reviewed By ( '\ Work Plan Date O�G57 ❑C-57 Authorization for Other to Sign Permit orker's Camp ❑Workers Comp Waiver ❑Encroachment Permit C� dK.ss Agreement ead Agency Approval FR COMMENTS/CONDITIONS: WP TYPE I PE I SC FEE INFO JAMT REMITTED1 CHECK#I RECV-D BY I DATE I WELL PERMIT# INVOICE# Permit -Z�+4N 1 $152 x �-�j i}7`15i tiX � QL"„ ,7 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site MiU aUon Well Permit Application 7i 03 5"L3 ��Z X 3 cl S X co 1,7 5 cr J 75 7 -�