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�iUlfy SAN JOAQUIN Environmental Health Department -C O U N T Y-- Foa� 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 1320 W Weber Avenue City/State/Zip Stockton CA 5203 Phone 209-948-0793 Cross Street W Washington Street APN 145-190-22 Property Owner* Andy Gabriel Phone 410-371-6934 Address 1320 W Weber Avenue City/State/Zip Stockton CA 95203 C-57 Contractor Cascade Drilling License# C-57 1058336 Phone 707-378-3768 Address 3459 Collins Avenue City/State/Zip Richmond CA 94806 Consultant/Sub-Contractor-Roux License# A HAZ 964122 Phone 415-967-6000 Address 555 12th Street, Suite 250 City/State/Zip Oakland CA 94607 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 25 feet bgs ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25-inches ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ® SOIL BORING 2 ❑ PUSH POINT(GP/CPT) -CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER ® OTHER: Direct Push GROUT SEAL PUMPED? m Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDS Temporary Borings RB-01 and RB-02 GROUT SPECIFICATIONS Neat cement grout to the surface. 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: Temporary enivornmental borings for groundwater sample collection.Borings will be abandoned on the same day after sample collection,using a tremie pipe and neat cement grout to the surface. 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 Title/Company Senior Geologist, Roux Associates, Inc. Print Name E I y Siegel Date 1/23/2026 DEPARTMENT USE ONLY I Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name L1,, C p l FA Address ILzj _0 i.v Lv.G� FA# �G Z � � PR# 0 5 FA PE 2. 1ate' WP Reviewed By U Work Plan Date �.��C Z (� ❑C-57 [ C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑ Encroachment Permit ❑Access Agreement "Lead Agency Approval I!FMFR COMMENTS/CONDITIONS: t,Z� WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RE V'D BY DATE WELL PERMIT# INVOICE# Permit )�'1,i'>� �j l $179 x j `f P, ' . i. 2 ZG' W P OL(oM4 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 07-01-2025 J`4 -' ,i I t;,,51 Site Mitigation Well Permit Application