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SAN JOAQUIN Env�rcnfmeritral Health Depar".tnent <br /> -----COUNTY--- <br /> Greotness prows he,-w­ . PA JjN-r <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATIO1 M <br /> For Wells and Borings Used for Contaminant Investigations and Remediati F?eCejVeD <br /> � 0 6 2019 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED SAN JOAQUIN CO <br /> Advaiice �NV-jce Requirev.11. For All Inspectfons ENVIRON <br /> UN-ry <br /> HEALr�j D MEN7AL <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. 'PAII%§WT <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Stan <br /> Job Address 17200 Murphy Parkway City/State/Zip 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/State/Zip Lafayette, Colorado <br /> C-57 Contractor Penecore Drilling, Inc License# 906899 Phone (916)-753-5127 <br /> Address 220 N East St City/State/Zip Woodland California <br /> Consultant/Sub-Contractor Advanced GeoEnvironmental License# 680227 Phone (209)467-1006 <br /> Address 837 SHAW ROAD CityiState/Zip STOCKTON,CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: OffsIte BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ❑ HOLLOW STEM BORING DEPTH 15, E:I BOLTED TRAFFIC BOX [I STOVE PIPE <br /> [I EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2" []MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA <br /> [3 SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0,020 TYPE OF CASING: E]STEEL []PVC [] OTHER <br /> El SOIL BORING 24 91 PUSH POINT(GPI CPT) CONDUCTOR CASING [I Yes 0 No Boring Dia: Casing 01a: _Casing Depth: <br /> El INJECTION IA.i Sparse,ozone) [I HAND AUGER GROUT SEAL DEPTH 15, TREMIE TYPE TO BE USED: 0 AUGERS El HOSE [0 PIPE <br /> C] OTHER 0 OTHER:_ GROUT SEAL PUMPED? 0 Yes ID No (Note:Maximum Freefall Depth Is 30 Ft) <br /> WELU SOIL BORING IDs 131-824 GROUT SPECIFICATIONS PORTLAND TYPE 11 <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of—inches to depth of feet <br /> WELL I Ds O PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS El EXPLOSIVES From—to feet below surface <br /> TREMIE TYPE TO BE USED 0 AUGERS [:]HOSE El PIPE 0 MUSHROOM CAP El 3 feet below surface or—feet below surface if>3 feet <br /> COMMENTS: ..See attached Work Plan and site plan <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Z� Title/Company SENIOR GEOLOGIST/AGE <br /> Print NarAe"baniewil anueva Date 3/4119 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: J r E&116M —Date Issued: 3 jL� <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# P <br /> FA PE WP Reviewed By Work PlanData 1 <br /> [3 C-57 [I C-57 Authorization for Other to Sign Permit []Worker's Camp [I Worker's Comp Waiver [j Encroachment Permit [I Access Agreement El Lead Agency Approval [IMFR <br /> COMM ENTSICONDITIONS: <br /> I <br /> WP TYPE I PE I SC I FEE INFO REMITTED1 CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE4 <br /> VVP <br /> T <br /> I Permit I qqjS1 1$1.52 x 131 1 . 11 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitgation Well Peant Application <br />