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SAN JOAQUIN Environmental Health Department COUNTY Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 267ooeanta Road City/StatelZlp Tmcy,CA95304 Phone (916)769-3272 Cross Street west Unne Road APN 252n6o 0eo 000 Property Owner' 26700 S BANTA ROAD LLC Phone (916)7693272 Address 38137M Steel CilylState/Zip Saemmenta,CA95916 C-57 Contractor AdvancadGeo,Inc. License# 106376S Phone (B00)511-9300 Address 837Shaw Road City/State]Zip Sloddon CAM216 Consultant/Sub-Contractor Advanc:dGeo,Inc. License# 10621765 AYto Zl g / z Phone (900)511-9300 Address 637 Shaw Road City/StatelZip SRddcn CA 95215 CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsM/ells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 feet ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION NporMaler) El HAMMERIDRIVEN DIA.OF BOREHOLE 1.5Inches ❑MULTIPLE CASINGS MULTELEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS WA TYPE OF CASING: [I STEEL [I PVC ❑ OTHER ® SOIL BORING 10 19 PUSH POINT(GP/CPT) CONDUCTOR CASING El Yes [I No Noting Dia: Casing No: Casing Depth: ❑ INJECTION(asoale.Ozare1 ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USED: ❑AUGER ❑HOSE [I PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? [I Yes [I No (Note:Maximum Freafall Depth is 30 Ft) WELU SOIL BORING IDs S-1 throuoh S-10 GROUT SPECIFICATIONS PoNandty Il cemanlI surtece gods C Wen DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel WELL IDS ❑PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feel below surface TREMIE TYPE TO DE USED El AUGERS [I HOSE Q PIPE I ter,/❑MU HROOMC 3feet bet surface or feet below dace if>3 feel COMMENTS: I .� L��CI. LNT \ 4S - :>1� '. C 1 hereby certify that 1 am authorized to complete thisapplication and that tife work will be done in accordance with �t�I San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. L j Signed 'l . � _ Title/Company AdvancedGec,Inc. Print Name Maxwel Niemeyer Date Mac, 0 .2024 � (� DEPARTMENT USE ONLY ? / '/ Application Accepted By: ,y+.�(�t(Zy t/� ( "� Date Issued: J Z of 20?4 Grout Inspection By/Date � 11 Destruction Inspection By/Dales: Facilit /Site Information .-, FA Name /w1,II oe- �' 1 . FAAddress � � s, FA# OC'Zpo 10-Z PR# o54.gL p 1p, FA PE l•-Z_ O WP Reviewed By Work Plan Date L./26 2Lt- PFW ❑G57AuthorzationforOtherto Sign Permit ❑Workers Gomp El Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement [I Lead Agency App✓meal "FIR COM?pMENTSICOONDITIONS: S,46a%;+- COf y o(— rrs`t.l+.s -tomSRO ?-Pr SC- WekkWAcla. s t7 •� 1. WP TYPE I PE SC FEE INFO AMT REMITTED CHECK# I RECV'D BY DATE WELL PERM♦IT# INVOICE# Permit CIQS a $162x $ L 319/V V41r of 1-r 5 1868 E. Hazelton Avenue I Stockton, Calif o nil 95205 LT 209 468-3420 1 F 209 464-01 ww dPd.COm EHD2MI 0& c. n �01-17 (-:4- b Ci 3 7i� 3 Site Mitigation Well Pennit Applica6en