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0 ` �0 =410:�W 'cZ SAN JOAQUIN Environmental Health Department I � 's COUNT Y 4r: c�A116Fr ; 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 `` Address PO Box 567 City/State/Zip Stockton , CA 95201 C -57 Contractor AdvancedGeo , Inc . License# 1063765 Phone 800-511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 Consultant/Sub -Contractor AdvancedGeo , Inc . License# 1063765 Phone 800-511 -9300 Address 837 North Shaw Road City/State/Zip Stockton , CA 95215 CONSTRUCTION WORK TO BE PERFORMED : * Note : Offsite BoringsNVells 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 ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER ® SOIL BORING 3 ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ® No Boring Dia : Casing Dia : Casing Depth : ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH Entire 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 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 � PQ4t_ Title/Company Project Geologist Print Name Brian Millman Date 13 April 2022 DEPARTMENT USE ONLY �—� �— Application Accepted By : IVADate Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information FA NameroQr e eC FA Address 2 FA# o b gq PR# 6 5 4Q 9 2drZ FA PE 2Q bQ WP Reviewed By Work Plan Date SN or Z6 Zo J, rk g O� C-57 ❑ C-57 Authorization for Other to Sign Permit El Comp El Workers Comp Waiver ElEncroachment Permit ElAccess Agreement p^ead Agency Approval MFR b. COMM ENTS/CONDITIONS : 0 rk ko (r.f �cvie1 94t* S"TII5 Gl l � V WP TYPE PE SC FEE INFO AMT REMITTED CHEC # I RECV' D BY DATE WELL PERMIT# INVOICE# Permit ZQ � rJ 3 I3 1 $ 152 x :3C) 4 C Z ( 00L f9 3 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . sjcehd . com EHD 29-01 04-04-07 Site Mitigation Well Permit Application