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= nU'" SANAOAQUIN Environmental Health Department COUNTY `�oqr 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'Rtle,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 5300 W. Woodbridge Rd. (1 05 N iZ`jClry'iS-4te/Zip Lodi, CA 95242 Phone Cross Street N. Ray Road APN 01116011 Property Owner* Paula J. Lind Trust /Todd Marley Phone Address 19105 Ray Rd. City/State/Zip Lodi, CA 95242 C-57 Contractor Gregg Drilling License# 1044456 Phone 925.313.5800 Address 2100 Goodyear Rd. City/State/Zip Benicia, CA 94510 ConsultanVSub-ContractorJacobs Engineering Group,Inc.(Jonathan Ferris)License# Phone 505-280-9088 Address 2101 Webster Street, Suite 1410 City/State/Zip Oakland, CA 94612 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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparse,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 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 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETER of 6 inches to depth of 20.5 feet WELL IDs 1VW-1 ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland Cement Type 1/II ❑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: Overdrill,backfill with cement to within 3 feet bgs.Backfill to surface with native material. 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 ��irGe4.Q.� Title/Company Gregg Drilling LLC. Print Name David Moses Date 0er02/25 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name v,�52 �ti.�( ddress ✓v (u✓c r FA# p A 4- PR# rj 3 elb j 1�� FA PE 1 qWP Reviewed By Work Plan Date IT)- ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: l,uk�(, WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RE V' BY DATE WELL PERMIT# INVOICE* Permit (.�b� 3 i 3 $172 x tZ �� L L Z"l 1 "w P 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 4 8-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 09-01-2024 2 pAk z V } Site Mitigation Well Permit Application