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r+ c.. gulp SANJ0A0UIN Environmental Health Department —COUNTY— 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 24498 N LOWER SACRAMENTO Rd CitylStatelZip Acampo, CA95220 phone 209-334-9780 Cross Street Jahant Road APN 003-15-022 Property Owner' Langetwins Limited Partnership Phone Address 1525 E Jahant Road City/State/Zip Acampo CA 95220 C-57 Contractor Gregg Drilling. License# 1044456 Phone 925-313-5800 Address 950 Howe Road City/State/Zip Martinez, California 94553 ConsultantlSub-Contractor Enviro Assessment, PC License# CA Civil PE 69045 Phone 844-742-7311 Address PO BOX 1154 City/Statemp Bonners Ferry,JD 83805 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsfte Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 IN HOLLOWSTEM BORING DEPTH 75' ❑BOLTED TRAFFIC BOX ®STOVEPIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERAIRNEN DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUDROTARY CASINGTHICKNESS 9" TYPE OF CASING: [I STEEL INPVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes ®No Boling Oia: Casing Die: Casing Depth: ❑ INJECTION WSosm O. awl ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: 91AUGERS El HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDS MW-4 and MW-5 GROUT SPECIFICATIONS Grout mixture 3 gallons potable water for each 47 lbs Portland cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED El OVER-BORE DIAMETER of_inches to depth of feet WELL IDS ❑PRESSUREGROUT To depth offeet below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED El AUGERS El HOSE ❑PIPE ❑MUSHROOM CAP ❑3feetbelowsurfaceor feet below surface if>3 feet COMMENTS: I lere rtify 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 Title/Company President/Fnvirn ACCeCSment, PC Print Name ja 14 R. i.Snn Date 5/20/2020 PARTMENT USE ONLY Application Accepted By: ZJL Date lip sue Grout Inspection By/Dates: Zr7lN Destruction Inspection By/Dates: Facilit /Site Information/ � k ,I� FAName �a/45 WI FAAddress 7 V AI, FM dO Sq8" PR# p,> FA PE Z96 WP Reviewed By 1 A } Work Plan Date 3 ❑CST C-57AuIWzationkr Olherto Sign Permit ❑ ker Wors Canp [I Workers Comp WaNVer�❑Encroachment Permit ❑Access Agreement Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: L„bmr.� su S/,Ip Oo I�� L W.� zWt 3 (2Uiog5 vers;ox 1" as f _Ic1R A. ky 4 1MCW { 1%;S 1/4.5idri i55Kd h) WP TYPE I PE SC I FEE INFO AMT REMITTED1 CHECK# I RECV-D BY I DATE I WELL /PE�RMIT# INVOICE# J Permit Zqo1 313 152 x 45G �l t �v,/ y' W r p / 00 ` 6 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD29-0108-01-17 612 0 Oa Sita:618Jge8� aell Permil Application