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S A N )Q A Q U I N Environmental Health Department COU NTY- . 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 23701 South Santa Fe Road City/State/Zip Rive rbank/CA/95367 Phone (209)550-1154 Cross Street Henry Road APN 249-060-120 Property Owner* Brilliant Nest Inc Phone Address 23565 S.Santa Fe City/State/Zip Riverbank/CA/95320 C-57 Contractor V&W Drilling License# C57#720904 Phone Address 1133 Blackhurst Drive City/State/Zip Galt/CA/95632 Consultant/Sub-Contractor Condor Earth License# PG#9945 Phone (209)513-7634 Address 188 Frank West Circle,Suite I City/State/Zip Stockton/CA/95206 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporNValer) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING []Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air SDdfne,Ozone! ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of inches to depth of feet WELL 11; MW-8 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Neat Cement [ EXPLOSIVES From 26 to 40 feet below surface TREMIE TYPE TO BE USED ❑AUGERS [—]HOSE ❑x PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel COMMENTS: Explosives will be placed below the sanitary seal to depth.Detenalion by Tylor McMillian Cert of Eligibility Bureau of Firearms#13854. 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Prdinance Codes and Standards,and all other applicable California laws. Signed �� — Title/Company Condor Earth Geologist 9 Print Name Luke Castle Dale / ) Application Accepted By: ZV17� EPARTMENT USE ONLYDate Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: 2 Facilit /Site Information FA Name R �4 Address Z 3 J �" FA# O O 253� PR# O FA PE �7 WP Reviewed By `! Work Plan Dale 1 P 2 ❑C-57 57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Camp Waiver ❑Encroachment Permit ccess Agreement Lead Agency Approval MFR COMMENTS/C N ITIONS: 01 WP TYPE PE I SC FEE INFO AMT REMITTED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 31 152 x 2 C O 11q is W Too �- 1868 E. Hazelton Aven��ulle I Stockton, California 95205 1 T 209 468-3 20 1 F 209 464-0138 1 www.sjcehd.com EHD 29-07 08-01-17 r �(�, a 1�'r M + 5-3/�-0�6 3 Site Mitigation Well Permit Application