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P QUr1V SA N$J O A Q U I N Environmental Health Department COUNTY Grenfness 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 306 Ham Lane City/State/Zip Lodi, CA 95240 Phone 800-511-9300 Cross Street Lockeford Street APN 037-100-300 Property Owner* Stone Bros & Assoc Phone 800-511-9300 Address 5250 Claremont Avenue City/State/Zip Stockton, CA 95207 C-57 Contractor AdvancedGeo Inc. License# 1063765 Phone 800-511-9300 Address 837 Shaw Road City/State/Zip Stockton, CA 95215 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone 800-511-9300 Address 837 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 6' ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 4 MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER "f't_ t hi>g ❑ SOIL BORING [1 PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.ozone) ❑ HAND AUGER GROUT SEAL DEPTH 4 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WEW SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement 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 su ce or_feej 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 Da4'e' Title/Company Senior Geologist Print Name Daniel Villanueva Date 06/23/2025 A�� DEPARTMENT USE ONLY �_ i Application Accepted By: -�L Date Issued: 1 �� Grout Inspection By/Dates: -T Destruction Inspection By/Dates: Facilit /Site Information -4 FA Name I FA Address FA# D D Z S' PR# FA PE v C (j WP Reviewed By Work Plan Date 2 9Q'.�-57 ❑G57 Authorization for other to Sign Permit orker s Comp ❑Worker's mp Waiver ❑Encroachment Permit ❑Access Agreement Dead Agency Approval RMFR COMMENTS/CONDITIONS: I j� S ,Q 5 f S ,, �✓t� r,s �� WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY D/ATTE-/, WELL PERMIT# INVOICE# / Permit 2°��S ��3 $172 x ! �;, CIL- �J 1 !l�l1 PQ500 91,25 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 0a-01-2024 Site Mitigation Well Permit Application