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- -�" ° SAN JOAQUIN Environmental Health Department C 0 U NTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Fours Advance Notice Required Ir-or Ali 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/State/Zip Linden, CA 95236 C-57 Contractor Confluence Technical Services, Inc. License# 1035255 t, l t �. 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 ._.JAISTALLATION TYPE CONSTRUCTION SPECIFICATIONS Soil Gas Probe 2"dia., 6' deep ❑ MONITORING �H`OLLOW STEM BORING DEPTH 70 feet [I BOLTED TRAFFIC BOX El STOVE PIPE El EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 8 inches ❑ MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA P9 SOIL VAPOR PROBE 1 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER L] SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarge.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-8, TH-9, TH-10, SG3 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: t�rt�; iirk (2 3 drilled borings and 1 soil gas probe. See Workplan and Water Board approval letter t r� ((e -fir Sc�,"( I)GI I hereby certify that I am authorized to complete this application and that the work will be done in accordan6e with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed / „ �,R `y p =„r�,,,l Title/Company President, Brusca Associates, Inc. Print Nam Joe Brusca Date 7/10/2023 DEPARTMENT USE ONLY 2 Application Accepted By: VDate Issued: K �'( 2 D Z:� Grout Inspection By Destruction Inspection By/Dates: Facili /Site Information Oq FA Name j i�-e �� t ; t+F1 Address Z V FA# d '� PR# 0FA PE '� P Reviewed By Work Plan Date G~�`Z ❑C-57, C-57 Authorization for Other to Sign Permit [IWorker's Comp ❑Worker's Comp Waiver [IEncroachment Permit ❑Access Agreement ad Agency Approval MFR COMMENTS/CONDITIONS: WP T1i'PE PE SC F INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# 411 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 WWW.Sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application