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SAN JOAQUIN Environmental Health Department -COUNTY- '=';�1F0--;._,f 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 17200 Murphy Parkway Cross Street D'Arcy Parkway City/State/Zip Lathrop, CA 95330 Phone (303) 607-5593 APN 198-120-05 Property Owner" San Joaquin Cogeneration, LLC Phone (303) 607-5593 Address 2575 Park Lane, Suite 200 City/State/Zip Lafayette, Colorado C-57 ContractorPenecore Drilling, Inc License# 906899 Phone (916)-753-5127 Address 220 N East St City/State/Zip Woodland ,California Consultant/Sub-Contractor Ad vancedGeo Inc . (AGI) License# 1063765 Phone (209) 467-1006 Address 837 SHAW ROAD City/State/Zip STOCKTON, CA 95215 CONSTRUCTION WORK TO BE PERFORMED: •Note: Offsite Borings/11\/ells Require Access Agreements or E ncroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATI ON TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING ___ 0 HOLLOW STEM BORING DEPTH 5-20' 0 BOLTED TRAFFIC BOX O STOVE PIPE 0 EXTRACTION (Vapor/Water) 0 HAMMERIORIVEN DIA. OF BOREHOLE 1.0-2.0" 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA _____ _ 0 SOIL VAPOR PROBE O MUD ROTARY CASING THICKNESS _--=_-=-_TYPE OF CASING: □STEEL □PVC O OTHER _______ _ @ SOIL BORING 30 l!O PUSH POINT (GP/ CPT) CONDUCTOR CASING O Yes O No Boring Dia: ____ Casing Dia: ____ Casing Depth: ___ _ 0 INJECTION (Ai' Spne Ozone) ___ 0 HAND AUGER GROUT SEAL DEPTH 5-20' TREMIE TYPE TO BE USED: 0 AUGERS O HOSE Iii PIPE O OTHER: ___ GROUT SEAL PUMPED? 0 Yes 1K) No (Note: Maximum Freefall Depth Is 30 Fl) 0 OTHER WELU SOIL BORING IDs 844-B73 GROUT SPECIFICATIONS PORTLAND JYPE U DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: /CHECK ALL THAT APPLY) # WELI.S TO BE DESTROYED _______________ □ OVER-BORE DIAMETER of __ inches to depth of ___ feet WELL IDs O PRESSURE GROUT To depth of ___ feet below surface GROUT SPEC IFICATI ONS O EXPLOSIVES From ___ to __ feet below surface TREMI E TYPE TO BE USED O AUGERS O HOSE O PIPE □MUSHROOM CAP O 3 feet below surface or feet below surface if >3 feet COMMENTS: •• See attached Work Plan and site plan .. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with Signed San Jqa�ul'!_ Coun�,,p::ce <;odes and Standards, and all other applicable California laws. �{L fl/l;j_ C:·Title/Company --=S:.::E::..:N.:.:IO::..:.R.:..;G:::.:E:.:O:.:L:.::O:.::G:.:.:IS::..;Tc..:c/..:..A:.::G:.::E'------------: » ' Print Name Brian Millman Date ____ o_3_Ju _n_e_2_0_20 _______________ _ DEPARTMENT USE ONLY Application Accepted By: _______________________ Date Issued: _____________ _ Grout Inspection By/Dates:---------------------------------------- Destruction Inspection By/Dates:--------------------------------------- Faci itv/Site Information FA Name FAAddress I I FA# I I PR # FA PE WP Reviewed By I I Worll Plan Date I OC-57 D C-57 Authorization for Other to Sign Permit D Workers Comp D Workers Comp Waiver D Encroachment Permit D Access Agreement D Lead Agency Approval □MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'DBY DATE WELL PERMIT# INVOICE# Permit $152x 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application