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�1 SAN�IOAQUIN a Environmental Health Department . `\ COUNTY Greatness grows her.-. 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 Developme t Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 5300 W. Woodbridge Rd. (I q 151 rj cdtyylate/Zip Lodi, CA 95242 Phone Cross Street N. Ray Road APN 01116026 Property Owner* Ashiq Javid 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 Consultarlb-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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIM 011'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/CP,n CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaroe.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 4 ®OVER-BORE DIAMETER of 6 inches to depth of 20.5 feet WELL IDs MW-2,IVI MW-4,PZ-3 ❑PRESSUREGROUT Todepthof feet below surface GROUT SPECIFICATIONS Portland Cement Type 1/II ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED FO AUGERS 171 HOSE PIPE MMUSHROOMCAP 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 applTication and that the work will be done in accordance with - ,,/San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed ��`rG�dQ Title/Company Gregg Drilling LLC. Print Name David Moses Date 06/02/25 _ DEPARTMENT USE ONLY Application Accepted By: t Date Issued: �� l�"� �Z Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name 1AAddeess 3 ,p ,b10f FA# rJp� '�cf� PR# FA PE Z 0 WP Reviewed By Work Plan Date Egil ❑C-57 Authorization for Other to Sign Permit CWorkees Comp ❑Workers Comp Waiver []Encroachment Permit ❑Access Agreement 19Lead Agency Approval [WFR COMMENTS/CONDITIONS: v1)I o' S V- �Ly,1 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 26t Ljk 3 `1$172 x ('-�2� I z (-t 5 W P a S 06-7 q ri 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3 20 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 2 o'k 2Ae-1 Site Mitigation Well Permit Application