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r ' SANIJOAQUIN p Environmental Health Department —COUNTY— '. GL,r�na�4 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 1449 French Camp Turnpike City/StatelZip Stockton/CA/95206 Phone 209-466-6692 Cross Street S Lincoln Street APN 165-030-200-000 Property Owner` Dean Sanders Phone 209-466.6692 Address P.O. Box 267 City/State/Zip Clements/CA195227 C-67 Contractor AdvancedGeo, Inc License# 1063765 Phone (800) 511-9300 Address 837 Shaw Road City/State/Zip Stockton/CA/95215 Consultant/Sub-Contractor AdvancedGeo, Inc. License# 1063765 Phone (800)511.9300 Address 837 Shaw Road City/StatelZip Stockton/CAI95216 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or EncrgachmntpPermits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ; IN GR{ C ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5-10feethsg ❑BOLTED TRAFFIC BOX ❑STOVE PIPE V ❑ EXTRACTION(Vapor/water) ID HAMMERNRIVEN DIA.OF BOREHOLE 125Ind- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA r ® SOILVAPORPROSE 2 ❑ MUD ROTARY CASINGTHICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOILBORING 5 17 PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes El No Soling Die: Casing Dla: Casing Depth: ❑ INJECTION PiSoaaa.Olme1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BE USED: []AUGERS ❑ E ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? Yms []No (Note:Maximum Fmetall pthls30FQ WELUSOIL BORING IDs Bi through B7 GROUTSPECIIFFIICCAATIION f^ a—n DESTRUCTION WORK TO BE PERFORMED: /r YrDESTRUCTION METHOD: (CHECK ALL AT APPLY) af/^I (/ IfWELLS TO BE DESTROYED [I OVER-BORE DIAMETER of_inches to depth of feel" / 7 V, WELL IDs ❑PRESSURE GROUT To depth of feel below surface /l J � GROUT SPECIFICATIONS El EXPLOSIVES From to feel balm sudace ✓?, TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE El MUSHROOM CAP ❑3 feet balm surface or feel belax sudace if>3feet COMMENTS: 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�pQGtn�Title/Company AdvancedGeo Inc Print Name lasleen ingh Date 04/12/2023 DE ARTM NT USE ONLY 7q Application Accepted By: Date Issued: LJ Grout Inspection BylDates: Destruction Inspection By/Dates: Facilit /Site Informal-on FA Name FAAddress 4'q lureA4 FA# 10I PR# FA PE Of J WP Reviewed By Work Plan Date C. �2 �Z e) ? ❑C-57AuftlzationfaOlherlo Sign Permit ❑Workers Comp ❑Wakens Comp Waiver ❑Encroachment Permit ❑Aocess Agreement 0LeWA9enq Approval FR COM ENTS/CONDITIONS: S'A L fplri ; a— I�,'v _ /� �� _(� �S� s /_v r 1 L WP TYPE PE I SC I INFO JAMT REMITTEDMmMi4VLpe ERMIT# INVOICE# Permit 2x `T`'t'1"� 1868 E. Hazelton Avenue I Stockton, California 95205 T 09 468-3420 1 F 209 464-0138 1 www.scehd.com EH029-0104-04-07 e L , `7 Lf- '�l �1 e(3 Site Mitigation Well Permit Applimlion