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SAN JOAQUIN Environmental Health Department COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation 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 250 East Roth Road City/State/Zip Lathrop, CA 95330 Phone N/A Cross Street South Mickinley Ave and Roth Road APN 196-030-01 Property Owner* Diamond Holdings of California, LLC Phone 209-983-4900 Address P.O. Box 156 City/State/Zip Meta, MO 65058 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-Contractor Ahtna Environmental, Inc. License# N/A Phone 916-396-5309 Address 2255 Contra Costa Blvd, Ste 312 City/State/Zip Pleasant Hill, CA, 94523 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/VVells Require Access Agreements or Encroachment Pen-nits TYPE OF WELLIBORING 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 5 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bodng Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IZI PIPE ❑ OTHER ® OTHER: Sonic GROUT SEAL PUMPED? []Yes []No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs Soil 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 ❑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 DEPARTMENT USE ONLY / 1 Application Accepted By: / � -✓. � Date Issued: -�I 7 i A � Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name aaxi FA Address FA# �7 t. 3 PR# �- '2-2--fc FA PE f`^ y', 4� WP Reviewed By �y 7( `—W`otrk Plan Date l it,657 ❑C-57 Authorization for Other to Sign Permit orkees Comp ❑Worker's Comp Waiver ❑Encroachment Permit I4ccess Agreement EKead Agency Approval 52'I1FR COMMENTS/CONDITIONS: WP TYPE I PE I SC FEE INFO JAMT REMITTED CHECK#I RECV'D BY DATEqq r WELL PERMIT# INVOICE# Permit Vic)J $152 x 5 ��+ tl j-' 1 'J'lli It W �✓5d 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 08-01-17 Site Mitigation Well Permit Application