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SHAM IN Environmental Health Department 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 with ISan Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 3105 S.El Dorado Street J'7C Ivtw / City/State/Zip Stockton CA95206 Phone (209)466-3554 ' Cross Street w.Ivy Avenue APN City of Stockton ROW (VJt,;W 110 �J' I Property Owner* City of Stockton ROW(EP#25-1332) Phone Address City/State/Zip StocktonCA95206 C-57 Contractor Baja Exploration Inc License# 804318 Phone (760)743-7678 Address 246 Vista Grande Glen City/State/Zip Escondido CA 92025 ,y.Cons ultant/SUb-Contractor Innovative Environmental Solutions(IES) License# 962676 Phone (760)632-2330 Address 839 Second Street Ste.2 City/State/Zip Encinitas,CA 92024 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(Vapor/Water) ❑ HAMMER/DRIVEN 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(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarge,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) WELUSOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 13 X OVER-BORE DIAMETER of 8-10 inches to depth of 30-85 feet WELL IDs See below PRESSURE GROUT To depth of 3 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: Well IDs: MWa,MW-7 MW-8,MV 1122B.,MW-13A,MW-14B,M 19B,M 6C,MW-178,MW-18C,MW-19B,MW-20C MVI-L{,Mv"O,t-Aw--1,, 'Mw -1Zt3,MW -13R MW-VIK to be raiLw►-' ruvkO sue to Itfiliffa (tint ip( J I hereby certify that I am authorized to complete this application and that the work will be done in accordance with To U&ovec,( San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /ywG. (,` Title/Company President,IESIAgent Print Name Michael Davis Date August 15,2025 l DEPARTMENT USE ONLY Application Accepted By: _ tt/\. Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates:��. Facility/Site Information FA Name I r FA Address l ��( u v FA# I CX11 2 PR# b ` ct)j,Y FA PE 2 d WP Reviewed By Work Plan Date ( y S 57 t�1457 Authorization for Other to Sign Permit rker's Comp ❑Worker's Camp Waiver PffEncroachment Permit ❑Access Agreement ad Agency Approval MFR COMM NTS/CONDITIONSAPoZ { 50 5 7 WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PE/�RMIT# INVOICE# Permit �� l; ',t> $172 x ��✓ �"I a-50 1 @ 1 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 2-1A_�Z`t Site Mitigation Well Permit Application Z�-� 3i2 1 o j