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SAN JOAQUIN Environmental Health Department —COUNTY 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 306 North Ham Lane citylstatelZlp Lodi, CA, 95242 Phone 209-474-1818 Cross Street West Lockford Street APN 037-100-300-000 Property Owner' Stone Bros&Associates Phone 209-474-1818 I� Address 5250 Claremont Avenue CilylState/Zip Stockton, CA, 95207 .t2( C-57 Contractor--PeneeereBnitIr1 ' - C 7e. j/I.t� License# 906899-- 16 59 3 j 1-3 Phone 453B}66800— Ad `"'c'dress 22atireet 3 5-47 a �� IHS LlV City/StatelZip �loodland�6/+9"'O 2`�jt C��y-'g0,�j 7 Consultant/Sub-Contractor AdvancedGeo, Inc. License 63765 Phone (800)511� Address 837 Shaw Road City/State/Zip Stockton, CA 95215 16 `d CONSTRUCTION WORK TO BE PERFORMED: 'Note: OffsHe BodngstWells Require Access Agreements or Encroachment Permits O4,t( TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS per- i ,v ❑ MONITORING El HOLLOW STEM BORING DEPTH :a ❑BOLTED TRAFFIC BOX ❑STOVE PIPE V ❑ EKIRACTION(VapMatef) ❑ HAMMERORIVEN DIA.OF BOREHOLE 91 Mill aCASINGS MULTIUVEL WELL CASING DIA �a,l ® SOILVAPORPROBE 10 ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ® PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Dia: Casing Ua: Casing Depth: ❑ INJECTION Memel.Ozonal 111 HANDAUGER GROUf SEALDEPTH 15TREMIETYPETOBE USED: AUGERS ❑ HOSED PIPED Yes No ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ ❑ WELUSOIL BORING IDS GROUT SPECIFICATIONS grout to be placed byeemmie pipe DESTRUCTION WORK TO BE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) PERFORMED:# ❑ OVER-BOREDIAMETER of_inches to depth of_feel PRESSURE WELL IDs# ❑GROUT To depth of_feet below surface GROUT SPECIFICATIONS TREMIE TYPE TO BE USED Portland type 11 cement [1 EXPLOSIVES From_to feel below surface ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP ❑ 3 feet below surface or feel below surface if>3 feet COMMENTS: All boring wit be bacldilled upon completion Mlh neat cement at a rare no great"than 5 gallons per 94 pound sack 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 pagle¢� kl4azw'zyi Title/Company Senior Geologist/AdvancedGeo, Inc. Print Name Daniel Villanueva Date 20 December 2023 Application Accepted By: ` DEPARTMENT USE ONLY Date Issued: Grout Inspection By/Dates: 'fit y g zo23 Destruction Inspection By/Dates: r Z Facilit /Site Information G FA Name V.1o0c� n( (0.Z1L FAAddress pt FA# � fi5 PR# II FA PE WP Reviewed By Work Plan Date `ZQ W Z 'md4W C-57 ❑G-57 Au0adzation for Other to Sign Permit ❑Workers Gomp ❑WCor`k`eLr's CompWalver ❑Encroachment Permit ❑AClce Agreement ❑Lead Agency Approval ❑MFR CO EN SICONDITIONS: 5abA* rPsa `{S {0 PAD S - UJL� '` rt� feuola--(o ftm e �le�rd � ?ZOO WP TYPE PE SC I FEE INFO -" JAMTRENHTTEDJ CHECK# I RECV'RBYII DATE I ELL PERMITS INVOICE# i / Permit p' s 14- C IZ zv Z3 Do4-5 S t 1-3�-Zz all 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464 0138��w5www..sjcehd.comif Cthtz� LED 29-0704-04-07/O Juper� s /!� r &'�k-� She Mitlgaron W¢Il PeriYil Application