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v +.�V'"c SANsJOAQUIN a '� Environmental Health Department t COUNTY- Greotness 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 200 E Madruga Road City/State/Zip Lathrop/ CA/ 95330 Phone Cross Street EB Hwy 120 APN 241-02-070 Property Owner* CHI LTH GP, LLC Phone (949)698-8482 Address 527 W. 7th Street, Suite 108 City/StatefZip Los Angeles/ CA/ 90014 C-57Contractor v&w Drilling License# 720904 Phone (209)469-7700 Address 3806 Duck Creek Drive City/State/Zip Stockton/ CA/ 95215 Consultant/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 Borings/Wells 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(Vapor/Water) ❑ 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(Alrspame.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) WELLI SOIL BORING IDs ___ GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑x OVER-BORE DIAMETER of 8 inches to depth of 20 feet WELL IDs MW-S1 ❑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 &Q— /— Title/Company Staff Engineer/ENGEO,INC. Print Name Ana Lua Date o5-31-19 DEPARTMENT USE ONLY i Application Accepted By: Date Issued: Q �(.3 1!e� Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name FA Address e, FA# PR# � r il C arGynA� _ S t70'�73 cis�l3�l FA PE S� WP Reviewed By Work Plan Date J 3 J ❑C-57 Ef C-57 Authorization for Other to Sign Permitorkees Comp ❑Worker's Comp Waiver ❑Encroachment Permit Wccess Agreement ❑Lead Agency Approval 94-WR COMMENTS/CONDITIONS:(7,; Sha u 64, ctf"O WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit ?y'I,i 4 '3 t 3 $152 x I bj L � 4.1 L-X b (jfat 1868 E. Hazelton Avenue Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Miligalion Well Permit Application