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S A N A Q Q U I N Environmental Health Department ` COUNTY-- c'9t��FioR`P 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 21801 E.Highway 120 City/State/Zip Escalon,CA 95320 Phone 209-272-3276 Cross Street Van Allen Rd APN 205-250-016 Property Owner* Barrel Ten Quarter Circle Land Co. Phone 209-272-3276 Address 21801 E.Highway 120 City/State/Zip Escalon,CA 95320 C-57 Contractor Cascade Drilling LP License# 938110 Phone 916-638-1169 Address 3000 Duluth St. City/State/Zip West Sacramento CA 95691 Consultant/Sub-Contractor Kennedy/Jenks Cons.Inc. License# N/a Phone 415-243-2150 Address 1676 North California St.,Ste 430 City/State/Zip Walnut Creek,CA 94596 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M MONITORING 1 ® HOLLOW STEM BORING DEPTH 95' ❑BOLTED TRAFFIC BOX ®STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 8.. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCH40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes K]No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air sparse,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 70' 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 MW-7D GROUT SPECIFICATIONS 5%Bent.-Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS [—]HOSE ❑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 Title/Company Print Name Date DEPARTMENT USE ONLY Application Accepted By: Aaron Gooderham Date Issued: 02/21/2021 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name Barrel Ten Quarter Cir Land Co. FA Address PO BOX 789,Ceres,CA 95307 FA# PR# FA PE WP Reviewed By Aaron Gooderham Work Plan Date 12/28/2020 ,11110 C-57 ❑C-57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement Vead Agency Approval V4FmFR COMMENTS/CONDITIONS: Call inspection line 48 hours in advance of grouting, EHD staff shall be present during grout seal placement. (209)953-7697 WP TYPE PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 2901 313 $152X 1 $152.00 Card I AG 01/26/2021 1 WP0041672 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Confirmation Number: 119752187 Site Mitigation Well Permit Application