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S A N 10 A Q U I N Environmental Health Department T SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 17200 Murphy Parkway City/State/Zip Lathrop, CA 95330 Phone (303)607-5593 Cross Street D'Arcy Parkway APN 198-120-05 Property Owner* San Joaquin Cogeneration, LLC Phone (303)607-5593 Address 2575 Park Lane, Suite 200 City/State/Zip Lafayette, Colorado C-57 Contractor Penecore Drilling, Inc/Slagle Drilling Corporation(wellSL)icense# 906899/1046151 Phone (916)363-9354/ Address 220 N East St/3369 Fitzgerald Road Suite B City/State/Zip Woodland/Rancho Cordova, California(916)753-5127 Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone (209)467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 4 ® HOLLOW STEM BORING DEPTH 15'&20' IRl BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2"&8.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE _❑ MUD ROTARY CASING THICKNESS 0.020 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER I SOIL BORING ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes El No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 15'&2' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE-®HOSE-ff PIPE ❑ OTHER _❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/ BORING OsMW-1 -MW-4 GROUT SPECIFICATIONS PORTLAND TYPE II 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: **See attached Work Plan and site plan** I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San?paquin County Ordinance Codes and Standards,and all other applicable California laws. Signed �e Title/Company SENIOR GEOLOGIST/AGE Print Name BRIAN MILLMAN Date 2/25/19 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Z Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver []Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 1.4 $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 ( F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application