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Consultant/Sub-ContractorApex Envirotech, Inc <br />SAN .1(lMillIN O1ill(7-.q .oji:;:ll flildo iq -10;101111.1C-.414: <br />Phone (209) 292-8175 Job Address 3032 Waterloo Rd <br />Cross Street Stitro Ave <br />City/State/Zip Stocklom, A. 95205 <br />APN 143-140-300-000 <br />Address 220 N. East St. City/State/Zip Woodland, CA, 95776 <br />Licenser/ Phone (916) 851-0174 <br />Address 11291 Pyrites Way, Suite R City/State/Zip Gold River, CA 95670 <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO RE USED AUGERS D HOSE 0 PIPE <br />COMMENTS: This permit does not include the two soil vapor wells off site as proposed in the AGE work plan <br />Dale Issued: 8/25/2021 Application Accepted By: JEFFREY WONG <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dales: <br />Facilit /Site Information <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />2/1 Hours Advance Notice Required For All Inspection; <br />CALL (209) 953-7697 For INSPECTIONS <br />Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Property Owner* Deputy Dhaliwal Phone (206) 310 1206 <br />Address 1233 N. Central Ave City/State/Zip Kent, WA, 98032 <br />C-57 Contractor Pert e Core Drilling License// 906899 Phone (530) 661-3600 <br />CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offslte Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />El MONITORING <br />0 EXTRACTION (Vapor/Water) <br />CI SOIL VAPOR PROBE <br />12) SOIL BORING <br />El INJECTION (Art $Peiqe. Ozone) <br />El OTHER <br />NUMBER INSTALLATION TYPE <br /> ID HOLLOW STEM <br /> D HAMMER/DRIVEN <br /> 111 MUD ROTARY <br />7 CO PUSH POINT (GP/ CPT) <br /> El HAND AUGER <br />El OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 10 feel <br />DIA. OF BOREHOLE 2.5 Inches <br />CASING THICKNESS <br />CONDUCTOR CASING D Yes ria <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS neat cement VVELUSOIL BORING IDs $EM 802, 8133, 504, 805, 806, S07 <br />DESTRUCTION WORK TO BE PERFORMED: <br />//WELLS TO BE DESTROYED <br />WELL IDs <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />0 OVER-RODE DIAMETER of Inches to depth of feel <br />El PRESSURE GROUT To depth of feet below surface <br />D EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP IJ 3 feel holow surface or feel beiry.v surface if >3 feet <br />Signed <br />Print Name <br />DEPARTMENT USE ONLY <br />EA Name <br />FA PE <br />Waterloo Food and Fuel _ <br />2957 <br />FA Address I 3032 Waterloo I FAll I FA0021303 PR/, PR0537118 <br />WP Reviewed By I JW Work Plan Date 1/9/2019 (by AGE) <br />ri C 5/ IRC-5/Authorbalnn for Other to Sign Permit 0 Mikes Comp 17 Worker's Comp Waiver El Encroachment Permit 0 Access Agreement -9 Lead AgencyApprovel M MFR <br />COMMENTS/CONDITIONS: <br />Submit copy of results to EHD per SJC Well Standards 13.7.2 <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE J WELL PERMITO INVOICEil <br />Permit 2905 313 $162x -; 456 cc JW 8/24/202 WP0042477 <br />1808 E. Flazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />DID 20-01 0G-20-21 Silo MIUgalion Well Parma ApplIcalion <br />Confirmation Number: 130604672 sr0084138 <br />U BOLTED TRAFTIC BOX 0 STOVE PIPE <br />Mt.11 BPI I- CASINGS 0 MIII II-1 EVI-1 WEI I CASING DIA <br />TYPE OF CASING: El STEEL El PVC CI OTHER <br />Borim Diil. Casing Dia Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />(Note: ?.laxknurn FrecIall Depth i Is 30 Fl) <br />oreljy certify that I am authorized to complete this application and that tho work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all othecappllcabto Callfornla law. <br />Title/Company <br />Dale