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` oP6uuv c� SAN _JOAQUIN Environmental Health Department —COUNTY 41Foa r (,rr^fn?ss 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 WELUBORING 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 ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 0 SOIL BORING 2 ❑ PUSH POINT(GPI 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 0 PIPE ❑ OTHER ® OTHER: Direct Push GROUT SEAL PUMPED? 0 Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELLI 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 enivommental 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 Siegel Date 1/23/2026 DEPARTMENT USE ONLY I I Application Accepted By: Date Issued: L Grout Inspection By/Dates: G rr Destruction Inspection By/Dates: Facili /Site Information t FA Name o cl f, 1 L 0 L b S FA Address t.-'7 10 w . Lv.G�n�L it FA# Uo Z 6 s>(3 PR# FA PE Z q )� WP Reviewed By Work Plan Date I L C Z L ❑G57 -57 Authorization for Other to Sign Permit ❑Worker's Comp []Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement 'JFPLead Agency Approval F"FR COMMENTS/CONDITIONS: Z 2) WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# REqNG2 BY DATE WELL PERMIT# INVOICE# Permit 2,010 1713 $179 x � L(� i Z 3 WPAW) 079, 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2M1 07-01-2025 ).`A.'�i I wVr Site Mitigation Well Permit Application