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'oycluiry �Q °z� SAN,J0AQUIN Environmental Health Department .JL COUNTY 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 826 North California Street and 517 East Flora Street City/State/Zip Stockton,CA 95202 Phone 209-468-0310 Cross Street East Flora Street and North American Street APN 139-175-160-000 and 139-175-120-000 Property Owner* County of San Joaquin Phone 209-468-0310 Address 44 North San Joaquin Street City/State/Zip Stockton,CA 95202 C-57 Contractor AdvancedGeo,Inc License# 1063765 Phone 800-511-9300 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor License# Phone Address City/State/Zip 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 ® HOLLOW STEM BORING DEPTH 5' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWaler) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA N/A ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N/A ® SOIL Boring 4 ❑ 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 �a PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ®No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDS 35 through 88 GROUT SPECIFICATIONS Portland Type II. py."k(,�✓r sr.� 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: /'q� �O'A (ij�C�w�h ve, Imo— Lowy A,S SoC( �. (�o� lro%-v r ALA Lp;�� S r:"it &y<— Slee work plan dated 04-10-2025 r4-v- n.: b-1 vu�b't L(r--\r rv-lt"- �0 yrci 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 ��/!/�Qi2. Title/Company AdvancedGeo.Inc Pont Name Maxwell Nierneyer Date 04/10/2025 DEPARTMENT USE ONLY Application Accepted By: �..��"' � Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA# PR# p,�li � � , C FA PE J WP Reviewed By Work Plan Date l .s 57 ❑C-57 Authorization for Other to Sign Permit [Workers Comp ❑worker's aiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval MFR COMMENTS/CONDITIONS: l l 0 l ctiu(c. f WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT# INVOICE# Permit 7XVA i yt� $172x A (% -14 a5 UJPas�� a0 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34ZQ I F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 L't cI Ib ir©j 0 Site Mitigation Well Permit Application