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r OI I1J r SANdQQQQIN Environmental Health Department 'I —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 City/StatelZip Lodi, CA, 95242 Phone 209-474-1818 Cross Street West Lockford Street APN 037-100300-000 Property Owner` Stone Bros&Associates Phone 209-474-1818 Address 5260 Claremont Avenue Cltylstate/zip Stockton, CA, 95207 C-57 Contractor Penecore Drilling License# 906899 L ' Phone (530)661-3600 Address 2200 North East Street City/Statelzi oodland, CA 9,5776 Consultant/Sub-Contractor AdvancedGeo, Inc. License 1063765 y-Mi'r v akf Phone (800) 511-9300 Address 837 Shaw Road City/Stale ockton, CA 95216 CONSTRUCTION WORK TO BE PERFORMED: *Note: OHsile Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑ HOLLOWSTEM BORING DEPTH 15,20.30 ❑ BOLTEOTRAFFICBOX ❑STOVEPIPE ©EXTRACTION(VapaM'aler) 8 ❑ HAMMERIDRIVEN DIA.OFBOREHOLE 6'and8' ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA []SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: [I STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑ Yes[] No Boring Dla: Casing Do: Casing Depth: ❑ INJECTION msoama.Ozarrel ❑ HANDAUGER GROUT SEAL DEPTH 7&6' TREMIETYPETOBEUSED: ❑ HOSE❑ PIPE❑ Yes No ❑ OTHER OTHER: GROUT SEAL PUMPED? El ❑AUGERS WEW SOIL BORING ID, WE -SVE-B IF GROUT SPECIFICATIONS grout to be paced by treouna pipe DESTRUCTION ORK TO BE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) PERFORMED:# ❑ OVER-BOREDIAMETER of_inches to depth of_feet PRESSURE WELL IDs# ❑ GROUT To depth of_feet below surface El EXPLOSIVES From_to feel below surface ❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet belay surface if>3 feet COMMENTS: Allboringallbebatl U� upmcomplegm Whneatcementetaroeomg aw Nan 5 gallons per94 pound sack I� n rtle�. d �l� ►�a�er;aQs 1�►xa f�l}ati� u , ctrz no I hereby certify that ram authorrzed to complete this application and that the work will be done in accordahce v611h q ' / San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. vtv[�� Signed �patGP,� [1ia Title/Company Senior Geologistl AdvancedGeo, Inc. UA Print Name Daniel Villanueva Date 08 May 2024 D PARTMENT USE ONLY �7 Application Accepted By: / Date Issued: /LJ „/Zo p�f Grout Inspection By/Dates Destruction Inspection By/Dates: T o Facil)t /Site of rmation FAName Vjda ZX�, FA Address 30 � --1�0.I� -A# �O 1„}6 +5 PR# 0 4-Q'Lf5_,3 FA PE WP Reviewed By Iso r Work Plan Date g 202 C27 ❑C-57 Au8arizagm for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waver ❑Enaaachmenl Permit ❑Access Agreemenl ❑Lead AgencyAp/p-roval ftFR COM ENTS/CONDITIONS: SssltQ� J w;ti (ZWAC cu Trace eraakt /26/20��f 2 s WP TYPE E SC FEE INFO AMT REMITTED CHECK# RECV'D BY DAT r WELL PERMIT# INVOICE# Permit 4e 1 - 3 3162 X L 4—$z cr 2 µ V� 24-o('k. CJW l S1b41$'S �o �� ec l8 �04 � y� I. 1868 E. azelton Avenue l Stockton, Cpyli or% 5205 1 T 209 468-3420 1 F 209 46�1 8 i www.sjcehd.com EHD 29-0104-04-e] s ( A?Pllc 1 ,. A4 ,M,.Atl he r� !1n/1 `.�t,�rQ C �a�n eMlggaAon Well Permit Appliratim