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$AN.dOAQUIN Environmental Health Department —COUNTY— �� neGreatness grows here. Z SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 14290 E.Comstock Road City/State/Zip Linden, CA 95236 Phone (209)351-0124 Cross Street Jack Tone Road APN 091-030-130-000 Property Owner' Anderson Barngrover Ranch Phone (209)351-0124 Address PO Box 127 City/StatelZip Linden, CA 95236 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 Phone (916)759-3512 Address 6821 8th Street City/StatelZip Rio Linda, CA 95673 Consultant/Sub-Contractor Bmsca Associates, Inc. License# CEG#1948 Phone (916)677-1470 Address PO Box 332 City/State/Zip Roseville,CA 95661 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS See Workplan for monitoring well specifications ❑ MONITORING 3 (2 HOLLOW STEM BORING DEPTH 80 feel ®BOLTEDTRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(VaponWater) Ll HAMMERIDRIVEN DIA.OF BOREHOLE 8inches ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Berth: ❑ INJECTION Mr Seems.ezonel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) t WELUSOIL BORING IDs MW1, MW2, MW3 GROUT SPECIFICATIO S - uJ . DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MET O : rCHECFCALLTHATAPPLYI #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of V feet Nek -/ A WELL IDS ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surfaceTREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE El MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 3 groundwater monitoring wells. See provided Workplan and Water Board approval letter 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 President, Brusca Associates, Inc. Print N1am Joe Bmsca Date 1/22/2024 DEPARTMENT USE ONLY �^T Application Accepted By: Date Issued: Grout Inspection By/Dales: �16 Destruction Inspection By/Dates: Faclllt /Site Information FA Name qr`kAA III e, jjtVrA iy.I FA Address Z ' FA# PRO FA PE WP Reviewed By Work Plan Date Z.O ❑C-57 G57 Au dzagonf oSign Permit ❑Workers Comp ❑Workers Comp Waver ❑Encroachment Permit ❑Access Agreement ❑Lead Agmx: Approwal COMMENTSI ONDITION �f �D 1IQ w fAc t r, 3 �f0,*t .A de-SCI- 15 20' Ok well svleeN- Cto'y ��i-10' 6e(e�W 4�✓I ti jWPTYPEj PE I SC FEE INFO AMT REMITT D CHECK# I RECV'D BY DATE rWpELL PERM�IIT�#J,� INVOICE# Permit L7 s1 w �� L 1 W 1 ?'quo, 1868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 1 F 209 464-1 8 w�.sjcehd EHD 29-0104-04-07 Site Mitigation Well Permit Application