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SAN J O A Q U I N 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 Boo E Madruga Road City/State/Zip Lathrop/ CA/ 95330 Phone Cross Street Guthmiller Road APN 241-03-013 Property Owner* CHI LTH GP, LLC Phone (949)698-8482 Address 527 W. 7th Street, Suite 108 City/State/Zip Los Angeles/ CA/ 90014 C-57 Contractor V&W Drilling License# 720904 Phone (209)469-7700 Address 3806 Duck Creek Drive City/State/Zip Stockton/ CA/ 95215 Cons ultant/Sub-Contractor ENGEO, Inc License# Phone (209)684-7604 Address 17278 Golden Valley Parkway City/State/Zip Lathrop/ CA/ 95330 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN 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 Spar-ge,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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 4 0 OVER-BORE DIAMETER of 8 inches to depthof 20 feet WELL IDS MWS2,MVV-S3,MVV-S4,MW-S5 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑x PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Gam-- �(-- Title/Company Staff Engineer/ENGEO,INC. Print Name Ana Lua Date 05-31-13 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: ho I It Destruction Inspection By/Dates: Facili /Site Information FA Name A4 1 (,c.nww�t FA Address �i0 I''l r S f— FA# �� L��7-�3 [PR# a& 3 q44- FA PE S WP Reviewed By _ Work Plan Date s-/3 )t ❑C-57 C-57 Authorization for Other to Sign Permit iXorkees Comp ❑Worker's Comp Waiver ❑Encroachment Permit Access Agreement ❑Lead Agency Approval MOR COMMENTS/CONDITIONS:(�-�v .,IL-�h <1�,5 d'e4-�&,� c�wy �v�� CM 4"t o✓-� MXn��{ C el' �it-y-t�l �t- ��.r.f,,,y�,�ti•��,Y.t,.�z{�1 .,.�•l d=sP��-ctJ( WP TYPE PE SC FEE INFO JAMT REMITTEDj CHECK# I RECV'D BY I DATE WELL�P2E(R�MIIT# INVOICE# Permit R,t71., ��3 $152 x � �:`C� L L_/ to �3 l tai PO e 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 �www.sjcehd.com —'fEH��Vj 1�3 S1iX � -isl 7 �I,b z. x 4 I'1 r r Site Well Ic�3c;APPlication A