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SAN J QAQ U I N Environmental Health Department COUNTY- GrCotrtes5 grows hem 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 t 909-North Stockton Street City/state/Zip Lodi,CA 95240 Phone Not Applicable cross Street Turner Road — APN 041-24-048 Property owner* Griswold Receivers for Norma Ackel Trust phone (858)481-1300 Address 171 Saxony Road,Suite 205 CltylState/zip Encinitas,CA 92024 C-57 Contractor Penecore Drilling License# 906899 Phan. (530)661-3600 Address 220 North East Street City/Statelzip Woodland,CA 95766 Consultant/Sul/-Contractor Stephen G.Muir Consulting Geologist License# CEG#1224 Phan, (209)601-6694 Address PO Box I S2 City/state/zip Woodbridge CA 95258 CONSTRUCTION WORK TP E R RMED-"Note: Offslte Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF wl LLIBORING NUMBER INSTALL9TI.RN TYPE CONSTRUCTION SPECIFICATIONS 0 MONITORING -0❑ HOLLOW STEM BORING DEPTH 15 gh@t ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapodWalor) ® HAMMER/DRIVEN DIA.OF BOREHOLE 3 In[1 S ❑MULTIPLE CA3iNGS❑MULTI-LEVEL WELL CASING OIA K SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: 0 STEEL d PVC ❑ OTHER ❑ SOIL BORING �❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ®No Boring Dig: Casing Dia: Casing Depth: ❑ INJECTION(air scabs.ozone/ `❑ HAND AUGER GROUT SEAL DEPTH 13 and 5.5 feet TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ICI PIPE ❑ OTHER ❑ OTHER; GROUT SEAL PUMPED? ❑Yes Di No (Nate,Maxlmum Freefall Depth Is 30 Ft) WELIJ SOIL BORING 106 AT-1 to 5 GROUT SPECIFICATIONS Hydrated bentonite for temporary installation see Fi ure 3 Please see attached Figure 2 far proposd soil vapor probe locations and Figure 3 dual zone soil gas well Completion diagram DESTRUCTION WORK TO BE PIERFORMED: DESTRUCTION METHOD;(CHECK_A11 JHAT APPLY) WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of!feel WELL IDs_ ❑PRESSURE:GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO SE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feat below surface or feel below surface if>3 feet COMM ENTro:"base see attached letter from RW OCR approving W orlkplan.Atraehed Figure 5 shows proposed completion of dual zone soil gas wells.The soil gas wells will be COmpl6tdd 6%Semi-p6 emenent with surface tralfic boxes,Grout to he used will be hydrated bentonite.We prcpva tv drill arrd lr%$Ull 145 foot deep soil gasprohe tip In each well followed byplanment of hydrated bentonite k r the deep zone followed by Install41140 Of 7.0 faat soil gas probe tip.Upper zone will not have hydrated bentonite grout Installed until SsceNo Impactor is present.Surface completion will Ineludr installation of steel traffic box.All soil gas wells will be everdrilla4 after soil gas investigation is completed under separate permit with SKIM hereby certify that 1 am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed t Title/Company w1 6. . Print Name Date +S. 7 Of DEPARTMENT USE ONLY Application Accepted By: � r a -� �� Date Issued: Grout Inspection By/Dates: Destruction Inspection BytOales; Feclli /Site Infoirmation FAName FA Address i t t r 7 EA# ) b PRfi It c - (, FA PE t-<j �-L. WP Reviewed By Work Plan Date ❑C-67 Cl C57 Authort$allon for Other to Sign Permit ❑Worker's Comp Q Workar's Comp Waly r b Encroachment Permll ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTSICONDITIONS., •j 17 U U -v y i I LAA f(- t �' �.j ! �:4>` ((rl i!-'V WP TYPE PE SC FEE INFO AMT REMITTIEU CHECKS RECV'D BY BATE WELL.PERMIT# INVOICE# Permit 41tu ) 5I $179x s`S 7 v Ir ' l-7 l' 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.S)cehd.co(-n EHO 29.01 07.01.2025 Site Mitigation Wet/Permit Application