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u '", c � n � ur<°c� r� rr>r� ental Health De; SAN JOAQUIN 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 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 AdvancedGeo, Inc. License# 1063765 Phone 900-511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone 900-511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 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 20 Feet ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE 2 inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 3 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes IZ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparse, ozone l ❑ HAND AUGER GROUT SEAL DEPTH Entire TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE la PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ® No (Note: Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs B51 , B52 , and B53 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 &�&w4a4� Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY Application Accepted By: Date Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA Name gp rAQr e � � FA Address 2 2 S r FA# o b Z gq PR' 6 51Q RZZ FA PE Za 6o WP Reviewed By Work Plan Date C-57 ❑ C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ead Agency Approval MFR COMMENTS/CONDITIONS : Su `� rk ko Nt> Wk� i �Q1 (1( , I S r� 1 ;?�r 'w WP TYPE I PE SC I FEE INFO JAMT REMiTTIED1 CHEC # I RECV'D BY DATE WELL PERMIT# INVOICE# Permit ZQo5 313 $ 152x 3 (� qk t/a I w5o L3 cw%�-�r (or YAk+. rn I Z 9 21 p Q q SA00 air 2 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www . sjc hd . com EHD 29-0104-04-07 Site Mitigation Well Permit Application