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a i Q SAN JOAQUIN Env "dr nrn ( � y� � o lea Dep �� ri �� . I `' COUNTY / Greotness grows here . SITE MITIGATION WELL & BORING PERMIT APPLICATION NON - REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance notice Required For All Inspections CALL ( 209 ) 9534697 For 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 500 East Louise Avenue City/State/Zip Lathrop , CA , 95330 Phone ( 925 ) 674-8400 Cross Street Harlan Road APN 198- 120- 120 Property Owner* ASP/ RWM Properties LLC , R & B Louise and Delta LLC Phone (925) 674- 8400 Address 1200 Concord Avenue Suite 200 City/State/Zip Concord , CA , 94520 C -57 Contractor Penecore Drilling Inc . License# 906899 Phone (916) 753-5127 Address 220 N East St . City/State/Zip Woodland CA 95776 Consultant/Sub -Contractor AdyancedGeo , Inc . License# 1063765 Phone ( 209 ) 467- 1006 Address 837 North Shaw Road City/State/Zip Stockton CA 95215 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 10 Feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA . OF BOREHOLE 2-3 Inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 15 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth : ❑ INJECTION (Air Sparge, 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 1380 - 1]1150 GROUT SPECIFICATIONS Portland Type II and not more than 6 gallons/94 Ib sack jr 4A Y �: P L5DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) 3 # WELLS TO BE DESTROYED [:] OVER- BORE DIAMETER of inches to depth of feet �� WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to 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 : See RWQCB Appproved work plan dated 6 -7 -22 and approval letter dated 1 -9 -23 1 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 (,j, ; Title/Company Senoir Geologist / AGI Print Name Brian Millman Date 01 March 2023 EP RTMENT USE ONLY Application Accepted By : `-' �� Date Issued : l �Z s' Grout Inspection By/ Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name rxj*. �i [,n N . A* � FA Address © FA# U j PR# (� 0 1 FA PE �Cj 5^ WP Reviewed By f Work Plan Date /''2 0 z ❑ C-57C 57 Authorization for Other to Sign Permit El Worker's Comp ❑ Worker's Comp Waiver El Encroachment Permit El Access Agreement ead Agency Approval MFR oe COMMENTS/d INDITIONISK �� ;J t, �/` j� S ( 2 ��`"►►�� WP TYPE PE SC FEE INFO AMT REMI ED CHECK# I RECV' D BY I DATE I WELL PERMIIT# INVOICE# Permit ob $ � , '� v� l Z 1� Q�� 7 1868 E . Hazelton Avenue Stockton , 1 lifornia 952051 T 209 468 3 - '420 1 F 209 464138 1 www .sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application