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SAN JOAQUIN Environmental Health Department ---COUNTY---- '- {.)reotness 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 COS ROW near Lincoln and Turnpike City/State/Zip Stockton, CA, 95206 Phone 209-937-8349 Cross Street South Lincoln Street APN N/A Property Owner* City of Stockton Phone 209-937-8249 Address 425 North El Dorado Street City/State/Zip Stockton, CA 95202 C-57 Contractor Hammerhead Drilling License# 1056569 Phone (707) 332-0966 Address 11345 Trade Center Drive City/State/Zip Rancho Cordova, CA 95742 Belle Court Consultant/ AdvancedGeo, Inc. License# 1063765 eq 2.1 2 V ZO2L Phone (800) 511-9300 Sub-Contractor Address City/State/Zip Stockton, CA 95215 837 Shaw Road CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparoe.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED One (1) [K] OVER-BOREDIAMETER of 8 inches to depth of 72 feet WELL IDs MW-12 ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Portland type II cement to surface grade ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [j]AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: MW-12 will be overdrilled to the total depth of 72 feet bsg and then grouted with neat cement. 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 �� Title/Company Senior Geologist/AdvancedGeo, Inc. Print Name Daniel Villanueva Date 02 May 2024 DEPARTMENT USE ONLY Application Accepted By: i Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: /AKe'ee-t— '�`Z'A3 z Facilit /Site Information FA Name �d � P FA Address 16 0 J r N•� FA# �� $ PR# 0 L) o 3 FA PE 2.9 6 0 WP Reviewed By c Work Plan Date to l 32 Q l�C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ALead Agency Approval KMFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE INVOICE# Permit 2L�L� L. 7 I $ i 2— �W SY�F;WZ1 191002 114� s �Bog 7-q �� 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 WWW.sjce com EHD 29-01 04-04-07 Site Mitigation Well Permit Application