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S A N J O A Q U I N Environmental Health Department 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 Stewart Road City7StatelZip Lathrop/ CA/ 95330 Phone Cross Street 5 Paradise Road APN213-61-005 Property Owner' River Islands Development LLC Phone (209)879-7900 Address 73 Stewart Rd City/State/Zip Lathrop/ CA/ 95�1.330 q C-57 Contractor Geo Ex License# 954267 Z}Df 31-IUVf Phone (866) 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/StatelZip Lathrop/ CA/ 95330 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsfWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXrRACTION(VapmANater) ❑ HAMMERIDRIVEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING [I Yes [I No Baring Dia: Casing Dia: Casing Depth: ❑ INJECTION Wswum.Ozarel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELD SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 2 ❑X OVER-BORE DIAMETER of 8 inches to depth of 23.5 feet WELL IDs MwR-27 aM MWR-28 II PRESSURE GROUT To depth of 22 feet below sudaoe GROUT SPECIFICATIONS neateement ❑EXPLOSIVES From to_feet below surface TREMIE TYPE TO BE USED [I AUGERS El HOSE W PIPE El MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS,priLs&uv Q— G ro - Dk—,' A(-"� CA, (,C-A (CeWt/lq-6?k .S041 1 hereby certify that l am authorized to complete this application and that the work will be done in accordance with Sawn Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed �-LlT Title/Company Prolect GeolmisVENGEO.INC. Print Name Codr Jonnson Date 09-12-2023 DEP61WtMENT USE ONLY �t Application Accepted By: Date Issued: / V �� Grout Inspection By/Date Destruction Inspection By/Dates: Facilil /Site Information FA Name �-(.5 /� FAAddress � �fp�0.r FA# M PR# o FA PE 6 r WP Reviewed By J l� w Work Plan Date 0C-57 7Aolhofoation fa Other to Sign Permit ❑Workers Canp ❑Workers CompWaimer ❑Encroachment Permit ❑Access Agreement 911e ad Agency Approval MFR COMMENTS/C NDITIONS: WP TYPE PE SC FEE•/I/NF/OY/ AMT REMITTED CHH'ECK# RECV-D BY 13 TIE WELL PERMIT# INVOICE# Permit oZ 313 dL� OarO`� 'to J ` C, I J ,0a0r -�9- O 1868 E. Hazelton Avenue I tockton, California 95205 1 T 209 468-3420 1 F 209 464-05t38o1frwww.sicehd.com EHD 29-0108-01-17 * ( 6 g, b/ Site Mitigation Well Permit Application 6