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F aU1N ' I%f tic°Z�, SAN 10AQUIN Environmental Health Department COUNTY , P Greatness gro ,vs 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 San Joaquin County Development Title , Chapter 9- 1115. 3 , and the San Joaquin County Well Standards , Job Address 2245 West Charter Way City/State/Zip Stockton , CA 95206 Phone 209-983-1111 Cross Street Tille Lewis Drive APN 163-360-170-000 Property Owner* Raymond Investment Corp . Phone 209-983-111 1 Address PO Box 567 City/State/Zip Stockton , CA 95201 C -57 Contractor Penecore Drilling License# 906899 Phone 530-661 -3600 Address 220 North East Street City/State/Zip Woodland CA 95776 Consultant/Sub -Contractor AdvancedGeo , Inc. License# 1063765 Phone 800-511 -9300 Address 837 North Shaw Road City/State/Zlp Stockton , CA 95215 CONSTRUCTION WORK TO BE PERFORMED : *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ® MONITORING 2 ❑ HOLLOW STEM BORING DEPTH 25 Feet ® BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 8 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS Sch 40 TYPE OF CASING: ❑ STEEL ® PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air sparge, ozone) ❑ HAND AUGER GROUT SEAL DEPTH 3 feet TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs MW-6 and MW-7 GROUT SPECIFICATIONS Portland Type II and not more than 6 gallons/94 Ib sack 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 feet 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 Wit, Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY 1 Application Accepted By: Date Issued : A O �� Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name Fc ►n2r FA Address y.s Q r FA# (7Z- $q PR# LIb 0 X22 FA PE O WP Reviewed By �� Work Plan Date fq7822, AetdGk 00 2Z C-57 ❑ C-57 Authorization for Other to Sign Permit Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement14 Lead Agency Approval14MFR COMMENTS/CONDITIONS : f 10 �Ssc t ( RAA t ,5 1A 2� Z WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# I RECV' D BY I DATE I WELL PERMIT# INVOICE# Permit I qo ` 313 $ 152 x 304 1Zq Z I VjPoo T> Z crneflil 0 r n+ +tgv\ Alk I1�t Zq z g 0 q q Shoo 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464 0138 I www . sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application