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C - I AN OAQUINEnvironmental Health Department COUNTY reotness 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 Address PO Box 127 City/State/Zip Linden, CA 95236 = Services, Inc. 1035255 $ �' , (916) 759-3512 C-57 Contractor Confluence Technical q— �►i j��L,,icense# ¢'!�P Phone J6821 8th_St ` Z �O City/State/Zip Rio Linda, CA 95673 Address , Consultant/Sub-Contractor Brusca Associates, Inc. License# CEG#1948 Phone (�)677-1470 .3 PO Box 332 tR'�k- Roseville, CA 95661 Pr _j V Address (_ ,pity/State/Zip (_T �Iy 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 ❑ OTHER I'] SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes El 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 +� El MUSHROOM CAP El feet below surface or feet below surface if>3 fe COMMENTS: �" S ,t rr of q-j, VI t� t 0\f I P)/t ; 4 1 7 �f '61.1' / . Ls C� ,�01 3 drilled borings. See Water Board letter dated 9/22/23 I r�_ �'\j �)_P_ r I�*r (kJe_'( 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. r Q Signed Title/Company President, Brusca Associates, Inc. ../� a Print Nam Joe Brusca Date 9/27/2023 ti DEPARTMENT USE ONLY Accepted B : 1 � Date Issued: /.. © / o Applicationp y i3. e'PAL 1 0 �1 Z j Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name ;-[rC :r i r1C # 1 FA Address '"'� �t+� S- FA# �C3 — �' P//R# FA PE C WP Reviewed By !��, Work Plan Date !2 f l ze ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement q.Lead Agency Approval EYWFR COMMENTS/CONDITIONS: /� s/1�� _�M(i (�I��i�J �C)11� vi+6- t°� ( r r '��Z n l ♦jay,-e r— j3 ul i j j'VJ l WP TYPE PE SC FEE INFO AMT RE��ppMITTED CttHECK# RECV'D BY DATE 1 ,�W�WELL PERMIT# INVOICE# Permit �ZQQJ� �. sj�Zx �{"1�� 1 " �� /414 vv�� `''� ;r y 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 04-04-07 Site Mitigation Well Permit Application