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SAN JOAQUIN Environmental Health Department <br /> --COUNTY— <br /> Greotness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work described. <br /> This application Is made In compliance With San Joaquin County Development Title,Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 639 West Clay Street City/State/Zip Stockton, CA Phone 209-948-0302 <br /> Cross Street South Harrison Street APN 147-071-10 / <br /> e`I Property Owner* DSS Company Corp. Phone 209-948-0302 <br /> Address 655 West Clay Street city/Statelzlp Stockton. CA 95206 <br /> C-57contractor Penecore Drilling License# 906899 Phone 530-661-3600 <br /> Address 220 North East Street citylstate/zip Woodland. CA 95776 <br /> 4't,YonsullanUSub•Contractor AdyancedGeo, Inc. License# 11O637R5 Phone 800-511-9300 <br /> Address 837 Shaw Road city/state/zip Stockton. CA 95215 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offshe Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OFWELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VapaclWaler) ❑ HAMMERA)RIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS D MULTI LEVEL WELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: DSTEEL ❑PVC D OTHER <br /> ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONWGTORCASING [I Yes ❑No Budhq GIs: Cmkg Ola: Cas4g Depth: <br /> ❑ INJECTION maomm.0zwl ❑ HANDAUGER GROUT SEAL DEPTH TREMIETYPETOBEUSED: DAUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Nola:Maximum Freeld Depth is 30 FQ <br /> WEWSOIL BORING IOs GROUT SPECIFICATIONS - <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 43 ®OVER-BORE DIAMETER of a am 10 Inches to depth of 10 feet <br /> WELL We See Attached Table ❑PRESSUREGROUT To depth of_feel below surface <br /> GROUT SPECIFICATIONS 6a EXPLOSIVES FromVarles to_feelbebwsudace <br /> TREMIE TYPE TO BE USED []AUGERS []HOSE ❑PIPE [I MUSHROOM CAP ❑3feelbelowsudaoeor feelbelav surface if>3 feel <br /> COMMENTS: All wells, with the exception of soil vapor sampling points will be destroyed by placing wireline explosives to the <br /> total depth of the well. After detonation all wells will be overdrilled to 10 feet bsg. Solt-vapor sampling wells will be <br /> overdilled with 8-inch augers to 7 feet bs . <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> , San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed P�IlAama [,a, Title/Company Senior Geologlst/AGI - <br /> PdntName Daniel Villanueva Date 06/24/2024 <br /> J DEP RTMEN BE ONLY _ { �1 <br /> Application Accepted By: L// Date Issued: f( J <br /> v <br /> Grout Inspection By/Date <br /> i <br /> Destruction Inspection By/Dates: E( 11J Ah hudAi, <br /> Facill ISile Information FANmoe w-UtTre"r-6 q FAAddress 6 1 C I a-t4 IFA# pp Zit 11 S PR# 20 <br /> FA PE `L WP RWwed By Woik Plan Dale Zql t :1. yz <br /> Vk47 DC57AulhodzaknIwOherlo Sign Penoll ❑WorkaesONV DWmau's CompWalver DEnsoadunenl Pemat DAcaasAreewnl AgencyAppm 14val MFR S-' <br /> COMMENTSICONDITIONS: -r tD r' M C tA `{ ah W g ( Ifs V r y1 S Q 6 cl . p� raw%- nj <br /> bael m q- V4tll y to tot bs +►.av� over-dr';1e - -F�-J 10' s9 <br /> Ne-0 'Po- rrls etHr-60 : ;Agl wi-. (l ublanb{ -f'41Q­ CA dov ekdl da s;4-Z . <br /> JWPTYPEJ PE I SC I FEEINFa, AMTREMITTED CHECK# RECV'DBY DATE I WELL PERMIT# INVOICE# <br /> Permit 2902 613 I42 A $, { r 4000 ect, /� jr Zz{/ty In) Z BOO 14 S <br /> Ii 43 CG* 123S 49b SRoo g�3 tZ <br /> 1868 E. Hazelton Avenue l Stoc ton, C nt 5 l T 209 468-3420 l F 209 464-0138 l www.sicehd.com <br /> EHD 2e017-01-2023 Sae Miggalion well Peens Appleagm <br />