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I - -------- -- S A N J o A Q U I N Environmental Health Department C0U `.1 .1 Y 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 FloLirs Advance Notice Required For All Inspections D 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 32319 N Staten Island Rd City/State/Zip Thornton,CA 95686 Phone (916)776-1531 Cross Street APN 069-020-190 The Nature Conservancy/Conservation Farms and Ranches Phone 916 Property Owner" _ _ _( )776-1531 Address 32319 N Staten Island Rd City/State/Zip Thornton,CA 95686 C-57 Contractor Professional Geologist License#_ GEO 8690,HG 1073 Phone (530)759-2484 Address 2827 Spafford St. City/State/Zip Davis,CA 95618 N Consultant/Sub-Contractor HydroFocus,Inc. License#�`; A40 'r i� �� Ftone (530)759-2484 l.�J t Address—2827 Spafford St. City/State/Zfp Davis,CA 9561 Se� M �.6 Z CONSTRUCTION WORK TO BE PERFORMED:"Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 6 ft ❑BOLTED TRAFFIC BOX ISI STOVE PIPE (4'PVC cover) ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA,OF BOREHOLE 6' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS 0.145 TYPE OF CASING: ❑STEEL ®PVC❑ OTHER ❑ SOIL BORING ❑ PU T(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: ____Casing Dia: 1_6' Casing Depth: 6 ft _ ❑ INJECTION(Air sparse.ozone) ❑($NDAUGETO GROUT SEAL DEPTH 211 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IM PIPE ❑ OTHER ❑ OT99R GROUT SEAL PUMPED? ❑Yes®No (Note:Maximum Freefall Depth Is 30 Ft) WELL/SOIL BORING 10s FW I FW 7 GROUT SPECIFICATIONS medium bentonite chips.neat cement mixed a=rdingto California Well&ndprg(Bull.7490 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__feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From__to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feetbelow surface or feet below surface if>3 feet COMMENTS: 1 hereby certify that I am authorized to complete this application and that the work will.be done in accordance With' pSann oaquin County/�rdinance Codes and Standards,and all other applicable California laws: x Signed � f�( Title/Company President-HydroFocus,Inc. Print Name Steven J.Deverel Date 02/25/2020 D_51PARTMENT USE ONLY Application Accepted By: Da e Issued: 2 ` Grout Inspection By/Dates: - Destruction Inspection By/Dates: Facility/Site Information FA Name J sJMJ ! Address 3 q �� ' A# 00 PR# p 5-45 0 T FA PE Z°l�O WP Reviewed By 1 A l Work Plan Date 'L f � 2� A ❑C-57 [I G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Compp Walvver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COOMMENTS/CONDITIONS:cJa f_M fi rePD�L .f, LH p /�C-ee f ( o v-) Lv i�,^.x 7-- da I-ys o ecae. 141�M!'�OT%k`, h�IIS /N14S'N�C dQ ioyQ4L /11r-(-- !I7(-ACA t10 1t jl dhws O, WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PER IT# INVOICE# Permit 2CI� I $152x �(I 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com EHD 28-01 08-01-17 S a Mitigation Well Permit Application ©8'49Z>b