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SAN JOAQUIN Environmental Health Department '.j 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 23701 South Santa Fe Road City/State/Zip Rive rbank/CA/95367 Phone (209) 550-1154 Cross Street Henry Road APN 249-060-120 Property Owner* Brilliant Nest Inc Phone Address 23565 S. Santa Fe City/State/Zip Riverbank/CA/95320 C-57 Contractor V&W Drilling License# C57 #720904 Phone Address 1133 Blackhurst Drive City/State/Zip Galt/CA/95632 Consultant/Sub-Contractor Condor Earth License# PG #9945 Phone (209) 513-7634 Address 188 Frank West Circle, Suite I City/State/Zip Stockton/CA/95206 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ElINJECTION(Air Sparqe,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑ OVER-BORE DIAMETER of inches to depth of feet WELL I® MW-8 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat Cement ❑x EXPLOSIVES From 26 to 40 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: Explosives will be placed below the sanitary seal to depth. Detenation by Tylor McMillian Cert of Eligibility Bureau of Firearms#13854. 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 Condor Earth Geologist Print Name Luke Castle -• Date EPARTMENT USE ONLY �O 7 Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: , Facilit /Site Information FA Name D � ",j Address 3 5 �� FA# 0 0 25�� PR# O FA PE �� WP Reviewed By Z Work Plan Date /3 ❑C-57 -57 Authorization for Other to Sign Permit El Worker's Comp El Worker's Comp Waiver El Encroachment PermitKccess Agreement Lead Agency Approval 9MFR COMM ENTS/C TIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# REC�V'D BY DATE WELL PERMIT# INVOICE# Permit 31 $152 x cc, � w O 1q r2 W 1� 1� 24 " 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3 20 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 (r„ a 1f (�� Site Mitigation Well Permit Application