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SAN JOAQUIN Environmental Health Department I U). COUNT Y `gctFon"� 'l Greatness grows here, SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Fours Advance Notice Required For All Inspections CALL (209) 9 3-7697 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/State/Zip 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 Address 5250 Claremont Avenue City/State/Zip Stockton, CA, 95207 C-57 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/State/Zip Stockton, CA 95215 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsA/dells Require Access,Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH In and Iq BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ElHAMMER/DRIVEN DIA.OF BOREHOLE ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE � t El MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑ SOILBORING ® PUSH POINT(GP/CPT) CONDUCTOR CASING .❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparse,Ozone) x❑ HAND AUGER GROUT SEAL DEPTH 15 TREMIE TYPE TO BE USED: AUGERS ❑ HOSE❑ PIPE❑ Yes No ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ ❑ WELL/SOIL BORING IDs GROUT SPECIFICATIONS grout to be placed by tremmie pipe DESTRUCTION WORK TO BE DESTRUCTION METHOD: (CHECK ALLTHATAPPCY) PERFORMED: # ❑ OVER-BOREDIAMETER'of_ inches to depth of feet PRESSURE �"�l�t►J WELL IDs# ❑ GROUT To depth of feet below surface `'�`�� P� S IC CA o an e cement C2, - ► G+ "el GROUT SPECIFICATION�TREMIE TYPE TO BE USED type EXPLOSIVES From to feet below surface El AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: All boring will be backfilled upon completion with neat cement at a ratio no greater than 5 gallons per.94 pound sack. I)WO re/V 6- 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. be-Core Signed Title/Company Staff Scientist/AdvancedGeo, Inc. �Zal Print Name Kylie Kucera Date 12 October 2023 Y-0 K DEPARTMENT USE ONLY Application Accepted By: Date Issued: 0 1- Z 2 Grout Inspection By/Dates: Destruction Inspection By/Da s: Facilit /Site Information FA Name FA Address C FA# PR# FA PE 2 WP Reviewed By Work Plan Date O 'Zo 57 ❑C-57 Authorization for Other to Sign Permit El Comp El Comp Waiver El Permit El Agreement El Agency Approval MFR X R CO MEN 3/CONDITIONS: 6-44-, %� �'d S �► ;��' D��- p�• , s 'f F1'�)� - , r � A 2 WP TYPE PE Sc FEE INFO AMT REMITTED C//HECK# RECV'D�BfY DATE WELL PERMIT# ,q INVOICE# Permit 2��N i3 $ �x �,�- �k� 1. L 'V" �U �iI Z W f� � T I IV cc l�� l/J D�-i 3 y _itAklA �k M to �I�/�2, 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com EHD 29-01 04-04-07 c,Site Mitigation VVell Permit Application �(1;_f (/ l .j ( fi