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)SAN4JOAQUIN <br />..- —COUNTY— <br />\ Vi• Greatness grows here. <br />7c) <br />Environmental Health Deplrtment <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />24000 Mountain House Road Job Address City/State/Zip Tracy, CA 95377 Phone (925) 674-8400 <br />Cross Street Highway 205 APN 209-460-350-000 <br />Phone (925) 674-8400 Property Owner* R & B Delta II LLC <br />Address 1200 Concord Ave Ste 200 City/State/Zip Concord, CA 94520 <br />(209) 467-1006 C-57 Contractor AdvancedGeo, Inc. License# 1063765 Phone <br />Address 837 Shaw Road City/State/Zip Stockton, CA 95215 <br />(209) 467-1006 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone <br />837 Shaw Road Address Stockton, CA 95215 City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLJBORING NUMBER <br />o MONITORING 0 <br />0 EXTRACTION (Vapor/Water) 0 <br />0 SOIL VAPOR PROBE U <br />181 SOIL BORING 5 <br />0 INJECTION (Air Soaroe, Ozone) 0 <br />0 OTHER 12 <br />WELL/SOIL BORING IDs B1 through B5 <br />BORING DEPTH 5 ft to 15 ft bsg 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 1.5 inches 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS N/A TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS D HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Portland type II cement to surface grade <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 1=I AUGERS 1:1 HOSE I=1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />El PRESSURE GROUT To depth of feet below surface <br />1=1 EXPLOSIVES From to feet below surface <br />LI MUSHROOM CAP 1J 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: Borings 81 and B2 will be probed to 15 feet bsg. Borings 83, B4, and 135 will be probed to 5 feet bsg. All borings wil be backfilled with portland type II cement to surface grade. <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 C. <br /> Title/Company Staff Geologist, AdvancedGeo, Inc. <br />Print Name Evan Schmidt Date March 2nd, 2021 <br /> <br />DEPARTMENT USE ONLY <br />G Date Issued: 3/31/2021 Application Accepted By: JEFFREY WON <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: ),Ot <br />Information <br />FA Name R & B DELTA PROPERTY FA Address 24000 MOUNTAIN HOUSE FA# FA0026452 PR# PR0546615 <br />FA PE 2950 WP Reviewed By JW Work Plan Date 3/2/2021 <br />J C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver El Encroachment Permit 0 Access Agreement 0 Lead Agency Approval IR MFR <br />COMMENTS/CONDITIONS: <br />SUMBIT REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECIPD BY DATE WELL PERMIT# INVOICE# <br />Permit 2905 313 $152x 3 456 CC JW 3/2/2021 WP0041886 <br />1868 E. Hazelton Avenue' Stockton California 95205_1 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />N EHD 29-01 08-01-17 CONFIRMATION UMBER 121460282 SR0083490 Site Mitigation Well Permit Application