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r SAN OA N Environmental Health Department C J COUNTY i 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 Address PO Box 127 City/State/Zip Linden, CA 95236 Confluence Technical Services, Inc. C-57 Contractor '� ,� tLicense# 1035255 �v�` t � Z� phone (916) 759-3512 Address 6821 8th Street Z 6CJTCity/State/Zip Rlo Linda, CA 95673 Consultant/Sub-Contractor Brusca Associates, Inc. '3 License# CEG#1948 Phone (916) 677-1470 PO Box 332 � Roseville, CA 95661 t Lr�t Address b "� City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING 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 [!] SOIL BORING 3 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ElINJECTION(Air sparse,ozone) ElHAND 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 s rface i >3 fe COMMENTS: 4,L LS 3 drilled borings. See Water Board letter dated 9/22/23 r �t ' S P t_ 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 I.A.A ' �;t'+�� +- Title/Company President, Brusca Associates, Inc. Print Nam Joe Brusca Date 9/27/2023 /DEPARTMENT USE ONLY pp p Y: Application Accepted B �� Date Issued: r /.I • C� 3 l � � Grout Inspection By/Dates: Destruction Inspection By/Date . r� Facilit /Site Information FA Name r�'t. FA Address 114 ZfrC) '-�/" FA# ()O — f PR# ell 5 Z � FA PE —Z WP Reviewed By 1 Work Plan Date 2 Z�'c'��+) f 1 /L3 ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement 919.ad Agency Approval ❑MFR COMMENTS/CONDITIONS: ( � _ _.,►Tr d c� r {'r (�� C�i'✓1� -{b� (�'l ��`� � r� 'F>vdJ 4�1.- J WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit "?lppo5 '3 13 st; x 8a1.� C1fj 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application