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SAN _JOAQUIN Environmental Health Department "' —COUNTY— " • ��1r�o�,, / 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) 963-7697 For INSPECTIONS Application Is hereby made to San Joaquin County for a peril to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9A 115.3, and the San Joaquin County Well Standards. 1 Job Address 40 South Union Street City/State/Zip Stockton/CAI96204 Phone 518-605-0966 Cross Street E Market Street APN 151-204.160.000 Property Owner` Victor and Tina Rosasco Phone 518-605.1166 Address 1708 Woodsbro Road City/State/Zip StocktonlCA/95206 C-57 Contractor AdvancedGeo, Inc License# 1063765 Phone (800) 511.9300 Address 837 Shaw Road City/State/Zip Stockton/CA195215 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton/CAI95215 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offstle BoringsNVells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5-10feet beg ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMaler) (9 HAMMERNRIVEN DIA.OFBOREHOLE 1.251ndm ❑MULTIPLE CASINGS❑MULTI-LEVELWELLCASING CIA ® SOILVAPORPROBE 4 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: [I STEEL ❑PVC ❑ OTHER ® SOILBORING 8 71 PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes [I No Boring Us: Casing Us. Casing Depth: ❑ INJECTION(Alr Smile.Ozoral ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Fl) WEWSOIL BORING IDS Bl through 38 GROUT SPECIFICATIONS fn Ov�l� DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:YCHECK ALL TVL74qPL #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs ❑ PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to_ feelhelowsudaw TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet COMMENTS: 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 V Title/Company AdvancedGeo_Inc Print Name Kylie Kucera Dale 05/26/2023 PA MENT USE ONLY Application Accepted By: Date Issued: 0 Grout Inspection By/Dates: Destruction Inspection By/Dales: Facilit /Site Information FA Name I,. FAAddress Ai6A FA# 0D �afj Pit# p FA PE Q WI)Reviewed By Work Plan Dale G57 ❑G57 AuWorization for Otherto Sign Permit ❑Workers Comp ❑Workers CompWaher ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approvl MFR COMM NTSICONDITIONS: S .�, no WP TYPE I PE I SC FE NFO AMjil LiD CHECK# RECV-D BY DATE WELL PERM? INVOICE# Permit o5 $ x K"j CC T\)J JY1?�lZ3 1 W roo c 1 z �8�99 SRoos 4 Z3 1868 E. Hazelton Avenue I Stockton, California 95205 I 004 8- 420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 0404-07 Site Mitigation Well Permit Application