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" �.J S A N :_J OAQ U I N Environmental Health Department > F i COUNTY Greatness 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) 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 w'th San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 950 Stewart Road /�_ City/State/Zip Lathrop, CA 95330 Phone 209-879-7900 Cross Street About 2,200 feet w of Somerston Pkwy and Stewart Road APN 2'11-�2'1-001 / 2, 1 0 21 QD 1 1 Property Owner* Califia, LLC �-to 1r 2 l r AN.S�e yA {-p i^yTr ��' Lam"�P kN� �t /Phone 209-879-7900 Address 73 W Stewart Road City/State/Zip Lathrop, CA 95330 C-57 Contractor Bradley and Sons Drilling and Pump Systems License# 1 414178 Phone 559-441-1401 Address 3625 S. Highland Avenue City/State/Zip Del Rey, CA 93616 Consultant/Sub-Contractor Luhdorff& Scalmanini, Consulting Engineers License# n/a Phone 530-661-0109 Address 500 First Street City/State/Zip Woodland, CA 95695 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑x MONITORING 3 ❑ HOLLOW STEM BORING DEPTH 800 feet 2MLTED TRAFFICBOX TOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 12.25 inches XI MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA 2 inches ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS fted 401F480A8A TYPE OF CASING: ❑ STEEL D PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑x No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Airsparae.ozone) ❑ HAND AUGER GROUT SEAL DEPTH Mint TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE x❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? D Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) I WELU SOIL BORING IDs GROUT SPECIFICATIONS Sand cement:10.5 sax mix/7 gal water --'r/YVL 160 ►t p DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) pr A49,C #WELLS TO BE DESTROYED N/A ❑ 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: Test well is to remain longer than 30 days to allow for longterm monitoring of ASR operations. 60e, -�rev%& N b -7o' -f-o 9coo` C-rofj ) w;« ►� F� t�� ►�� e . hereby certi at I am authorized to complete this application and that the work will be done in accordance with Joaquin County Ordinance Codes and Standards, and all other applicable California laws. 'n " C,,' " Signed_ /% Title/Company Project Hydrogeologist Luhdorff& Scalmanini, Consulting EEngin era� rb Print Name Andrew Francis Date 5/13/2022 Dki � �' A-5-100EPARTMENT USE ONLY 6 22 Application Accepted By: V Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates p/ Facilit /Site Information `e C4P i FA Name °lh e FA Address i� l/I/Q FA# oQ Z g PR# 0 7Z C �� FA PE 2 `j� V WP Reviewed By I Work Plan Date 2 Q /Q J ❑ C-57 C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit Access Agreement ❑ Lead Agency Approval 1AFR io,Q/ j COMMENTS/CONDITIONS: M .4(t; iv- Wets 3 `� ® K "[^i s �Qrvh i� ,r1� u d�Y6�/e ®"1 by e t4anp "an KS P ►ato 1s�1 by Ty l6 M lit rll�n c0 y 64 Ad or-, 5�3 ` 1�/L° P i o ,--p 'IK Z and +eed--� b e l+m PKblic. Wddr, 'r, / Lw WP TYPE PE SC FEE INFO AMT REMITTED1 CHECK# RECV'DBY DATE WELL PERMIT# INVOICE# �j� Permit 2+1 31 $152 x 3 T✓v C :TVA , 6 1 IV 2 W P o 0 tt3 WZ-Wetis0-re— Ao r s.fr-V6'&, SRoaSs 305 1868 E. Hazelton Avenue I Stockton, California 95205 1. T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 CQA '% (rA0L 4Y1 V� I ktZ" I *qq Site Mitigation Well Permit Application