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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 fora 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 1173 North Main Street City/State/Zip Manteca,CA 95336 Phone 610-765.7095 Cross Street Lancaster Drive APN 21 6-3 604 20 Property Owner* Ralph 8.C Aquaro Trust Phone 610-766.7095 Address 1437 Chestnut Drive City/StatelZip Manteca CA,95336 C-57 Contractor AdvancedGeo inc. License# 1063765 Phone 209467-1006 Address 837 Shaw Road City/StatelZip Stockton,CA 95215 Consultant/Sub•ContractorAdvancedGeoine. License# 1063765 Phone 2094674006 Address 837 Shaw Road City/State/Zip Stockton,CA 96216 CONSTRUCTION WORK TO BE PERFORMED:'Note: O#slte Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5.15,25 ❑BOLTEDTRAFFIG BOX ❑STOVE PIPE ❑ EXTRACTION(VaporM'aler) ❑ HAMMENDRNEN DIAOFBOREHOLE If ❑MULTIPLE CASINGS[3 MULTtLEVELWELL CASING IXA 19 SOILVAPORPROBE 2 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC❑ OTHER ® SOIL BORING 7 ® PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Bodog Ole: Casing Dia: Casing Depth; [3 INJECTION rars 0eorel ❑ HANDAUGER GROUTSEALDEPTH 5,15.25 TREMIE TYPE TO BE USED: [I AUGERS [3 HOSE iM PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:MW=m Freelai Depth is 30 R) WELU SOIL BORING We Seemap GROUT SPECIFICATIONS Portland Cement 6 Palms per 94 Me sack DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [IOVER•BORE DIAMETER of_Inches to depth of_feel WELL IDs ❑PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE []PIPE ❑MUSHROOMCAP ❑3 feelbelow surface or feet below surface if>3 feet 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 SENIOR GEOLOGISTIA.G.]. Print Name Daniel Villanueva Date I t. 2q. VD DEPARTMENT USE ONLY Application Accepted By: Aaron Gooderha ,.h Date Issued: 01/07/2021 Grout Inspection By/Dates �iav� Destruction Inspection By/Dates: Facili /Site Information FA Name Tire and Break Pro's FA Address 1173 Main Street FA# PRN FA PE Win Reviewed 8y I Aaron Gooderham Work Plan Date 12/22/2020 MC57 ❑C57Augwka5onf"otherto Spn Permit ❑Workers Comp ❑Wodrers Comp Waiver ❑Encroachment Permit ❑Access A9re=61 ❑Lead A9eMAPPMX %MFR COMMENTS/CONDITIONS: Soil Vapor Probes shall be over-bored, removing all materials from the boring and backfilled with neat cement, when sampling is complete. jVVPTYPEl PE I SC I111 AITTED CHECK# RECV'D BY �01 DATE WELL PERMIT# INVOICE# Permit 2905 313 $162x 3 $456.00 CARD AG /05202 WP0041585 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD29-010eai•17 Confirmation Number 118381269 Ske MAI9aIien Wea PM1Applleatbn