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j AN OAQ N Environmental Health Department 'I0f17 COUNTY Greatness grows here, 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 PO Box 127 Linden, CA 95236 Address City/State/Zip C-57 Contractor Confluence Technical Services, Inc. License# 1035255 phone (916) 759-3512 Address 6821 8th Street City/State/Zip Rio Linda, CA 95673 Consultant/Sub-Contractor Brusca 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 ❑ MONITORING ® HOLLOW STEM BORING DEPTH 70 feet ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 8 inches ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC [__1 OTHER ff] SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,ozone) ❑ HAND AUGER 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) WELL/SOIL BORING IDS TH-11, TH-12, TH-13 GROUT SPECIFICATIONS 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: 3 drilled borings. See Water Board letter dated 9/22/23 1 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 Nam Joe Brusca Date 9/27/2023 DEPARTMENT USE ONLY Application Accepted By: h' c'�1%� Date Issued: v //�• ® �� Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information ?? FA Name i yl(' - � �; o r FA Address �ct C. iY�I S'L�t�Ct� FA# — PR# ZJ FA PE _Z_9 WP Reviewed By �� Work Plan Date lZ ►� C+-) ❑ C-57 ICI C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement pad Agency Approval Q14dFR COMMENTS/CONDITIONS: „ ici `,�--o-rXeS bo`� �.—� ` WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D�� 99BY DATE `W�WELL PERMIT# INVOICE# Permit ''j , "� j $i "�x v1/ I .. Vv 00''�� Li`J- � 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application