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a�orn�, co�a. SANSJOAQUIN y- Environmental Health Department —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 35100 South Highway 33 C tit Per) City/SlatelZip Vernalis CA 95385 Phone 209.835.7597 Cross Street South Welly Road APN 25-518-008 Property Owner• NnMieA,4a-6elnlions-N+e�leRte/el--Ke/ai�n-BertrarttY 5;9-C- R6VIJ Ipq 6�7/�0/W /f� -PIh_one 30"ft.29�82 Address 4ZB5 ^' ^'' "" 1SjD /oltzefI A City/StatelZip Loyola ,Cffd olopd�538t 70, 16 � C C-57 Contractor Cascade ^ ^ License# 1058336 Phone 7 000 a Address PO Box 1184 City/State/Zip Woodinville Washington 98072 4 \ Consultant/Sub-Contractor Rubik Steve Meninger-Senior Geologist License# CA-PG No.8853 Phone 775.432.0247 Address 320 Flint Street CltylStatelZip Reno NV 89501 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite BoringsAA/ells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 0 HOLLOW STEM BORING DEPTH 65 ®BOLTED TRAFFIC BOX ®STOVEPIPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMERIDRNEN DIA.OF BOREHOLE 6-inch ❑MULTIPLE CASINGS[I MULTI.LEVELWELLCASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASINGTHICKNESS SCH-40 TYPE OF CASING: ❑STEEL la PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Din: Casing Depth: ❑ INJECTION MIrsuaee.ozawl ❑ HANDAUGER GROUTSEALDEPTH THEME TYPE TO BE USED: ®AUGERS El HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? O Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELUSOIL BORING IDS MWER and MWBR GROUT SPECIFICATIONS neat cement W seal DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED OVER-BORE DIAMETER of_ _inches to depth of feet WELL IDs []PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS neat cement El EXPLOSIVES From_to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet COMMENTS: 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 Alulh /L 964; EA Title/Company Numien Aq SdutionS Inc.ISr Manager.Environmental Remedialion Print Name Kevin Bertrand Date June 3, 2020 DEPART ENT USE ONLY 2 �7 / J Application Accepted By: 00 C' Date Issued: �1 �•� iii! �tJ Grout Inspection By/Dates: A �,2gD Destruction Inspection BylDates: Facilil (Site Information / FA Name 1159 lM-. t* FA Address 3J �� 1"lW FA# oDn 'L PR# Q.0 FA PE et 60 W'P Reviewed By Work Plan Date ;h�- ❑C-57 ❑G57Aulhorizatbnfw Otherto Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permil ❑Access Agreement ❑Lead Agency Approval ❑MFR COMM ENTSICON DITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY D TE VilgiL PERM/IT# INVOICE# Permit M()k 3J ? $152X Z © � Z w 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 20, 464- 38 I AW.sjceh .Corn EHO 2MI 0801-17 Site Mitigation Weg Permd Application