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Q'oP S A N'10 A Q U I N Environmental Health Department ---C O U N T Y-- !/ 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 1762 West Hammer Lane City/State/Zip Stockton/CA/95209 Phone 2094774813 Cross Street Alexandria Place APN COS ROW near 07728031 Property Owner* Sims-Grupe Management Corporation,Inc Phone 209-478-9200 Address 374 Lincoln Center City/State/Zip Stockton/CA/95207 C-57 Contractor PeneCore Drilling License# 906899 Phone 530-661-3600 Address 220 N East Street City/State/Zip Woodland/CA/95776 Consultant/Sub-ContractorGeosyntec consultants License# N/A Phone 916-287-2946 Address 3043 Gold Canal Drive City/State/Zip Rancho Cordova/CA/95670 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 20 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 0 SOIL VAPOR PROBE 3 ❑ MUD ROTARY CASING THICKNESS 1/4"tubing TYPE OF CASING: ❑STEEL ❑PVC N OTHER Polyethylene tubing ❑ SOIL BORING ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) la HAND AUGER GROUT SEAL DEPTH 20'bsg TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE Tremle ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? []Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs SV1,SV2,SV3 GROUT SPECIFICATIONS Neat Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 3 0 OVER-BORE DIAMETER of inches to depth of feet WELL IDS SV1,SV2,SV3 N PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS neat cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP 0 3 feet below surface or feet below surface if>3 feet COMMENTS:SVPs shall be destroyed by removal of contents (ie: overdrill with geoprobe) and backfilled with neat cement. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with ��jj��// San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /14ZZ(� Title/Company Engineer/Geosyntec Print Name Katherine Clark Date 12/3/25 DEPARTMENT USE ONLY Application Accepted By: Date Issued: 12/3/2025 Grout Inspection By/Dates: 1, r \ p`t Destruction Inspection By/Dates: FacilitVISite Information FAName Park Woods Cleaners FAAddress 1744 W Hammer FA# 0024399 PR# 0542458 FA PE 2960 WP Reviewed By Work Plan Date �9/3/2025 ®C-57 N C-57 Authorization for Other to Sign Permit ®Workers Comp ❑Worker's Comp Waiver ®Encroachment Permit ❑Access Agreement ®Lead Agency Approval ®MFR COMM ENTS/CONDITIONS• 3 offisite borings for soil vapor nd GW investigation on COS ROW (Ha mer Lane) fort e Park Wood Cleaners site . +( �ib �, v F IMIC> ikSi�IU 5z e�& W 1no� tw� u u� L WP TYPE PE SC FEE INFO AMT REMITTED CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit 2905 313 $179 x 3 537.00 2 23792s 12/3/2025 W Po25013 g g 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 Site Mitigation Well Permit Application