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r. SA N J O A Q U I N Environinental Health Department <br /> —COUNTY--- <br /> I yjy <br /> fop': �C <br /> SITE MITIGATION WELL& BORING PERMIT APPLICATIO�a�e~ "'� <br /> For Wells and Borings Used for Contaminant Investigations and Remediatit5MN 1) <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN <br /> 48 Hours Advance Notice Required For All Inspections e+vvinONM cOUNTy <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or in the work descdbe�rH DEAgRTArtAL <br /> In! i <br /> This application is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Stand"97 1 II <br /> I <br /> Job Address 17200 Murphy Parkway City/StatelZlp Lathrop,CA 95330 Phone (303)607-5593 <br /> Cross Street D'Arcy Parkway APN 198-120-05 <br /> Property owner' San Joaquin Cogeneration,LLC Phone (303)607-5593 <br /> Address 2575 Park Lane,Suite 200 City/StatelZip Lafayette, Colorado <br /> C-57 Contractor Penecore Drilling,Inc License# 906899 Phono (916)-753-5127 <br /> Address 220 N East St CltyiStatelZtp Woodland,California <br /> Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone (209)467-1006 <br /> Address 837 SHAW ROAD CltylState/Zip STOCKTON,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: OQslte BoringsAhleils Require Access Agreements or Encroachment Permits <br /> TYPE OF WELUBORING N IU dBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑ HOLLOW STELA BORING OEPTH 15' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑EXTRACTION(Vapor/Watei) i1 ❑ HAMMERORWEN OW.OF BOREHOLE 2' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS 0.D20 TYPE OF CASING:❑STEEL❑PVC❑OTHER <br /> ®SOIL BORING ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes❑No Boring Dix Casing Ola: Ca*Dark i <br /> ❑ INJECTION(AV SDYQ..OSan01 ❑ HAND AUGER GROUT SEAL DEPTH 1 g TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE O PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes M No (Note:Maximum Freese Depth Is 30 Ft) <br /> WELUSOIL BORING Los a G'_,I — U` Z GROUT SPECIFICATIONS PORTLAND TYPE II <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet beloyr surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet beloway >3 feet <br /> COMMENTS: ..See attached Work Plan and site plan <br /> !in CeotGtlS �' `> <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San JJooaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed / i 1 / \ Tille/Company SENIOR GEOLOGIST/AGE <br /> Print Nanie'DanieWi anueva — Dale 3/4/19 <br /> DEPARTMENT USE ONLY tr <br /> Application Accepted By: J r GA'S�G� Date Issued:�I /�G <br /> Grout Inspection By/Dates: <br /> Destruction inspection Sy/Dales: <br /> acllit /Slte Information <br /> FA Name FA Address FAA PRO <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C•57AuthodzadonforOlherloSlgnPemm ❑Worker's Camp ❑WaketsCompWalver ❑EncroachmentPamit ❑Access Agreement ❑Lead AgerlcyAWoval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE I PE I SC I FEE INFO 1AMT REMiT-rEDj CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# <br /> —d <br /> Permit `K� 152x I �5�,t7� 3 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01.17 Site Wilgalcn Well Pewit AR-Acation <br /> i <br />