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a Q SAN JOAQUIN Envy r� nrne t -d HeaKfi Departrrmon' -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 Gf\LL (209) 953-7697 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 Lathro Cross Street Harlan Road APN 198-120-120 Property Owner* ASP/RWM Properties LLC, R&B Louise and Delta LLC Address 1200 Concord Avenue Suite 200 C-57 Contractor Penecore Drilling Inc. Address 220 N East St. Consultant/Sub-Contractor AdvancedGeo. Inc. Address 837 North Shaw Riad 95330 Phone (925) 674-8400 City/State/Zip Concord, CA, 94520 License# 906899 City/State/Zip Woodland CA 95776 Phone (925) 674-8400 Phone (916) 753-5127 License# 1063765 Phone (209) 467-1006 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 ❑ MONITORING ❑ EXTRACTION (Vapor/Water) ❑ SOILVAPOR PROBE ® SOIL BORING ❑ INJECTION (Air sparge, Ozone) ❑ OTHER WELL/ SOIL BORING IDs B80 NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ HOLLOW STEM BORING DEPTH 10 Feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ HAMMER/DRIVEN DIA. OF BOREHOLE 2-3 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER 15 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: I -]AUGERS ❑ HOSE ❑ PIPE ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) J�^w 8150 GROUT SPECIFICATIONS Portland Type II and not more than 6 gallons/94 Ib sack (/ Y * P DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) F� # WELLS TO BE DESTROYED ElOVER-BOREDIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface rREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet :.OMMENTS: See RWQCB Appproved work plan dated 6-7-22 and approval letter dated 1-9-23 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 ( ; 4QA-- Title/Company Senoir Geologist / AGI Print Name Brian Millman Application Accepted By: � Grout Inspection By/Dates: t/ Destruction Inspection By/Dates: Fnri1ity/14i4n Infnrmnflnn Date 01 March 2023 EPARTMENT USE ONLY Date Issued: zo Z3 FA Name rkr.+- Ti [,n Ate. FA Address © FA# U j PR# (� o 90 FA PE C..-- I�Cj 1�'� WP Reviewed By Work Plan Date �''� LO ❑ C-57 C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ead Agency Approval 171MFR COMMENTS/ DITIONS �� u t, �/ V) S ( 2 WP TYPE PE SC FEE INFO AMT REMI ED CHECK# RECV'D BY DATE WELL PERMIIT# INVOICE# Permit?105� t(6L CC I - '--j ;;VF-3 'AROO(,lFi 3 ej 1868 E. Hazelton Avenue I Stockton, 1;alifornia 95205 1 T 209 468-3420 1 F 209 464-' 138 1 www.sjcehd.com EHD 29-01 04-04-07 Site Mitigation Well Permit Application