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SANJOAQtJ EnvironmerTLal Health Department ' COUNTY 'I„,,;,0 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 9-1115.3,and the San Joaquin County Well Standards. Job Address 600 East Louise Avenue City/State/Zip Lathrop,CA,95330 Phone 926-674-8400 Cross Street Harlan Road APN 198-120.08 Property Owner* ASP/RWM Properties LLC R&B Louise and Delta LLC Phone 925-674-8400 Address 1200 Concord Avenue Suite 200 City/State/Zip Concord,CA,94620 C-57 Contractor CASCADE DRILLING License# 1058336 Phone 916-616.1241 Address 3000 DULUTH STREET City/State/Zip SACRAMENTO CA 95691 Consultant/Sub-Contractor ADVANCED GEOENVIRONMENTAL,INC. License# 1063766 Phone 209467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON,CA 96216 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Bormgs/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(Vapor/Water) ❑ HAMMER/DRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS[I MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing DW Casing Depth: ❑ INJECTION rAksoar .Ozonel ❑ HANDAUGER GROUTSEALDEPTH 15feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE []PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No Note: imam Freefell Depth is 30 Ft) 1 WELD SOIL BORING IDS GROUT SPECIFICATIONS ( /✓t��lf_'(/� 11.0 fi 1[�f�'� /� " NF1..1 IDS- E44 it 01�4��[r�kl I= t. Z r!) t DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:I&ECKALLTHATAPPLYt '�S DIAMETER of 2&4 inches to depth of #WELLS TO BE DESTROYED 15 ®OVER-BORE 20 _JS feet WELL We MW-1,2,3,4;RW-12,3,4 5,6,7,8;W-4;W-7,W-8 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONSPortland Cement 6 gallons per 94 Ibs sack ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ®AUGERS []HOSE PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel COMMENTS: I hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with S Joaq in�ounty Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company PROJECT MANAGER/A.G.E. Print Name Brian Millman Date 04 March 2020 EPA TMENT USE ONLY 3 /2 20 koApplication Accepted By: Date Issued: Grout Inspection By/Dates: V or Destruction Inspection By/Dates vJ w:t ?/20/20ZO Facili /Site Information FA Name M M1 -A ik*v4t, FA Address 50V C v. i1 FA# O , 36� PR# 05-o62_93 FA PE 2"f/y & 5 WP Reviewed By G�� vu �Y" Work Plan Date G57 ❑G57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Perm ❑it Access Agreement ❑Lead Agency Approval ❑MFR W MOM NTS/CONDITIONS: „r 1 :"j g 4r� 7/'4/ZO V)P op M W' 1 40 Mw R W-1 +e AWf- rt 7�Z/Zv u1P. W `/ WP TYPE PE SC FEE INFO JAMT REMITTED1 CHIEECK# RECV-D BY ?DATE WELL PERMIT# �/ INVOICE# U Permit o 61 3 $152 x Z a DI( ., J v L0 6 L _ 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-0 F 209 464-0138 1 www.sjcehd.com EHD29-0109-01-17 ,\Gi1�1,�n,gRttavY�rP®rbTf�ication =((%%O D1 QG�Q L�Jf