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( °a'" SAN�JOAQUIN °�� Environmental Health Department \ IU I� —COUNTY o Lry Greatness grows here. 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 9-1116.3,and the San Joaquin County Well Standards. Job Address 2460 Toste Rd City/State/Zip Tracy, CA,25377 Phone Cross Street Grant Line Rd APN .288�017-= Z38-Iq 0-0 Properly Owner- LEWIS MANAGEMENT CORP. Phone (909)946-7523 Address 1156 North Mountain Avenue citylstate/Zip Upland,California 91786 C-67 Contractor Cascade Drilling : License# 938110 Phone (425)527-9830 Address PO BOX 1184 city/State/Zip Woodinville,WA 98072 Consultant/Sub-Contractor Avocet Environmental,Inc. License# 838470 Phone (949)296-0977 Address 1 Technology Drive,Suite C515 City/State/zip Irvine,CA,92618 CONSTRUCTION WORK TO BE PERFORMED:*Note: ONsite BoringsWells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTFAI BORING DEPTH 5.5 R. ❑BOLTEDTRAFFIC13OX ❑STOVEPIPE ❑ EXTRACTION(Vap/Water) ❑ HAMMERJDRIVEN DIA OF BOREHOLE 3.5" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA p. SOILVAPORPROBE 5 ❑ MUD ROTARY CASINGTHICKNESS 10 TYPE OF CASING:❑STEEL❑PVC M OTHER NyleRow®tubing ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes [I No Boring pa Casing Dior: Csskg Depgz ❑ INJECTION WSnmae 0, O HANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USER. ❑AUGERS❑HOSE❑PIPE ❑ OTHER ❑ OTHER GROLTURAL PUMPED? ❑Yes ONO (NOW mReelNl Depth 30 FQ WELUSOIL BORING IDS SV-4through SV-8 GROUT SPECIFICATIONS AAA DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #WELLS TO BE DESTROYED [A OVER-BORE DIAMETER of_inches to depth of_feet WELL IDS ❑PRESSURE GROUT To depth of_feel below sudace GROUT SPECIFICATIONS [I EXPLOSIVES From_to_feel below surface TREMIE TYPE TO BE USED AUGERS HOSE PIPE 0 MUSHROOM CAP ❑3 feel below surface or feel below surface it>3 feel COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done In accordance with j aquin ounty Ordinance Codes and Standards,and all other applicable California laws, Signed Title/Company Protect Engineer Avocet Environmental Inc. Print Name Darren Brandner Date 02106/2020 DEPARTMENT USE ONLY /I n /�D Z� Application Accepted By: j4yDate Issued: `1 Grout Inspection By/Dales: V./ tAb Destruction Inspection BylDates: m—yut- KA -v 3J.1&1114-2-0 Facillt ISI e lnfgrmation ,L FA Name q,rt,C2.S� i �? ' FA Address 2 60 �.� FA# 0 2� PR# Q- FA PE 5-O WP Reviewed By /S Work Plan Date ( /31 U l ❑C57 G57 Au"zaWn rorOflW to Sign Permit ❑Workers Comp ❑Workers Oomp Waiver ❑ErcroacrvrwI Pored ❑Access Agreement ❑LeM AgancyAppanai ❑MFR COMMENTSIC DITIONS:/µby �0�..1 6 r'�Qa O ��"ID vJ1 �A 1�- cl al-I3 s1 /Q.2Q IOJS C 7 I / 4t (/ WP TYPE PE sc FEE INFO ANT REMITTED C�H11ECbbK# REECv'D BY DATE / ERMff T- INVOICES Permit Z405- 313 $152x 30� IT�p2 �JIJ� Z�sjZO F00 ✓3J�+ 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 i F 209 464-01� EHD 29A10e-01-17 eke MagJ.'We11 Pans Apprkalian