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S A N J O A Q U IN Environmental Health 'Department - .-COUNTY 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 15634 Steinegul Road City/State/Zip Escalon, CA 95320 Phone Cross Street Lone Tree Road APN 229-12-004 Property Owner* Albert Veldstra Phone (209) 604-7939 Address 15634 Steinegul Road City/State/Zip Escalon, CA 95320 C-57 Contractor Cascade Drilling License# 1058336 Phone (510) 478-0858 Address 120 South 23rd Street City/State/Zip Richmond, CA 94804 Consultant/Sub-Contractor ATC Group Services LLC License# 1021509 Phone (209) 579-2221 Address 1117 Lone Palm Avenue, Suite 21OB City/State/Zip Modesto, CA 95351 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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sgarge.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) WELU SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DES YED 14, . • d ®OVER-BORE DIAMETER of 2 inches to depth of 150 feet WELL IDs MW1,MWA MUM,MW5,MW6,MW9,MW11,VW1,VW2,VW3,VW4,SG-1,SG-2 GROUT To depth of 150 feet below surface GROUT SPECIFICATIGR9 neat cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ®PIPE R MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feet COMMENTS: See ATC Monitorin W II Destructi n orkplan dated February 12, 2020 n � TC s' I hereby certify that I am duthorizecYto complete this apj2jY1cati6n and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Consultant / ATC Group Services LLC Print Name Todd Hafner pate 5/$/20 3 juit-f4 over � � � PO �n� d� RTMENT USE ONLY �7- Application Accepted By: Date Issued: CN Grout Inspection By/Dates: q Destruction Inspection By/Dates: \ ZJE72� Facilit /Site Information FA Name "iK FA Address ! (� � FA# Le Z PR# �5�� ' l 7 ! lA FA PE WP Reviewed By Work Plan Date iz/,?o { .f.2" ❑C-57 7 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: r y n ►'a �� z -l'v / em �l�lL( WP TYPE PE sC FEE INFO AMT REMITTED CHECK# R WD BY DATE WELL PERMIT# INVOICE# Permit 0 $152 x O Ilf1bg WU f06 40 9 3 g 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464- 13VIwwniv.sjcLehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application u