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S A N J O A Q U I N 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 Stewart Road City/State/Zip Lathrop/ CA/ 95330 Phone Cross Street S Paradise Road APN213-61-005 Property Owner* River Islands Development LLC Phone (209) 879-7900 Address 73 Stewart Rd City/State/Zip Lathrop/ CA/ 95330 C-57Contractor Goo Ex License# 954267 .gycp a'- 3t/ZCo Phone 1116) 942-2315 Address 1016 Lincoln Blvd City/State/Zip San Francisco, CA, 94129 Consultant/Sub-Contractor ENGEO, Inc. License# Phone (925)786-7895 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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapooWater) ❑ HAMMERORIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL [I PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(&seance.0zme1 ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: ❑AUGERS []HOSE []PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma)dmum Frerrall Depth is 30 Ft) WELD SOIL BORING IOs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 2 []OVER-BORE DIAMETER of 8 inches to depth of 23.5 feet WELLIDs MWR-279nd MWR-28 ITIPRESSUREGROUT Todepthof 22 feel below surface GROUT SPECIFICATIONS neat cement El EXPLOSIVES From_to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS [I HOSE PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS r) f 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 �A'— Title/Company Poelect Geelo9isVENGEO INC. Print Name Cody3ohnwo Date 09-12-2023 IDEPAWrMENT USE ONLY 11 Application Accepted Sy: Date Issued: Grout Inspection By/Date Destruction Inspection By/Dates: Factlit /Site Information FA Name `,�, �,(.S� FA Address �rp�Ll'� FA# ryi PR# Oj FA PE / WP Reviewed By e l t� w Work Plan Date ❑C-57 57 Aultionzalan for Otherto Site Permit ❑WMees Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval MFR COMM ENTS/C NDITIONS: WP TYPE PE SC FEE IINFO AMT RE(MIITTTED CHECK# RECV"D BY D TE WELL PERMIT# INVOICE# Permit oZ 3�3 dt� �r�5 3 `o (.., �Z Z OO 9-- O 1868 E. Hazelton Avenue I tockton, California 952051 T 209 468-3420 1 F 209 464-Al59'j'-� .sjcehd.com EHD 29-010"1-17 �q ( � g IL Site Mitigation Well Permit Application