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SA N ) OAQ U I N Environmental Health Department <br /> --COUNTY-- <br /> c1d�i ov�'4' Grentness grows her; . <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 3932 East Fremont Street City/State/Zip Stockton,CA,95215 Phone <br /> Cross Street APN 143-360-040-000 <br /> Property Owner* Bilal Muhammad Phone 707-486-8894 <br /> Address P.O.Box 1447 City/State/Zip Lod,CA,95241 <br /> C-57 Contractor Advanced Geo Inc. License# 1063765 Phone 800-511-9300 <br /> Address 837 Shaw Road City/State/Zip Stockton,CA,95215 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 12 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2 5" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> IZ SOIL BORING 6- ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: % Casing Depth: <br /> ❑ INJECTION(Air Sparse.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSt 0 PI� <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland type II Neat Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDS ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS []HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below Surface if>3 feet <br /> COMMENTS: -t 1�)� l D bit— <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> rk San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed ri;��- Title/Company Staff Geologist/Advanced Geo Inc. <br /> Print Name Jesse Murch Date 02/13/2026 <br /> DEPARTMENT USE ONLY ` <br /> Application Accepted By: / Date Issued: l v <br /> Grout Inspection By/Dates: / " a <br /> Destruction Inspection By/Dates: IJ <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: % ' •, s' <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $179 x I -1/-1wpl�I,.01 50 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 07-01-2025 Site Mitigation Well Permit Application <br />