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SAN JOAQUIN nvironmental Health Dep artment C n- Ll N i Y.-,grow,5 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 � 53 -7' 697 for INSPECTtOhIS Application is hereby made to San Joaquin County for a permit to construct and/or install the work described ., This application is made in cpmpliance with San Joaquin County Development Title , Chapter 9- 1115. 3 , and the San Joaquin County Well Standarcls . Job Address 14290 E. Comstock Road City/State/Zip Linden , CA 95236 (209) 351 - 124 Jack Tone Road Phone C ross Street APN 091 -030- 130-000 Property Owner* Anderson Barngrover Ranch Phone (209) 351 -0124 Address PO Box 127 City/State/Zip Linden , CA 95236 C"57 Contractor Confluence Technical Services, Inc. d 4 LwicensUrr �cp � r `�+ OWN Ga� 1035255 � / ,� one (916) 759m3512 Address 6821 8th Street Rio Linda , CA 95673 City/State/zlp ConsultanUSub-Contractor Brusca Associates , Inc. CEG #-1948 Licanse# PO Box 332 gyf27Zw-14ZQ... . Phone 9� Ad d res s Roseville , CA 95661 C ity/State/Z 41 P CONSTRUCTION WORK TO BE PERFORMED : 'Note: Offsit orings hVells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORI NG NUMBE R INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING 12 HOLLOW STEM BORING DEPTH 70 feet ❑ BOLTED TRAFFIC BOX ❑ S70VE PIPE ❑ EXTRACTION (Vaportwater) El HAMMER/DRIVEN DIA. OF BOREHOLE g inches 1:1 MULTIPLE CASINGS [:j MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING., ❑ STEEL El PVC El OTHER L7 SOIL BORING 3 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING f7l Yes ❑ No Boring Dia, Casing Diao Casing Depth: ❑ INJECTION (Air Sparc e Ozone ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 1:1Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs TW-1-- 1 , TH- 12, TH- 13 G DESTRUCTION WORK TO 13E PERFORMED : DESTRUCTION METHOD : IgHECK a,iL THAT APP �vi # WELLS TO BE DESTROYED OVER-BORE DIAMETER of inches to depth of feet WELL IN GROUT SPECIFICATIONS PRESSURE GROUT To depth of feet below surface ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO-..BE USED El AUGERS ❑ HOSE ❑ PIPE ❑COMMENTS : MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet 3 drilled borings . See Water Board letter dated 9/2 /23 I hereby certify that 1 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 A �, -t�,y;�� ItTitle/Company President, Brusca Associates, Inc. Print Nam Joe Brusca Date 9/27/2023 l [ _ PARTMENT USE ONLY— DI Application Accepted By: r�� JP� � ,z SPEW 44, Date Issued: �` � 3 Grout Inspection By/Dates: Destruction Inspection By/Dates : Fac'ilitv/S"' Ite Information FA ....... ...... 7z FA PE Name � �.� j� ,s � � � y�,t .�. C hi . r - FA Address � � � t� � • . FA# ------- � a WP Reviewed By Work Plan bate ��► � , El C-57 El C-57 Authodzarion for Other to Sign Permit ❑ Workers Comp ❑ Workers Comp waiver d Encroachment Permit Ej Access Agreement COMMENTS/CONDITI ONS : ❑ Lead Agency Approval 01AFR dip% 'ZO Uf ry 4P WP TYPE PE SC FEE INFO AMT REMITTE[? CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# A4 0> 4e4t Permit �q� � � � � $� OZX 1868 E . Hazelton Avenue � Stockton , California 952 05 � T 209 468-3420 � F 209 46�0 38Q wAw, s&eh d . comEHD 29-01 04-04-07 Site Mitigation Well Permit Application