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- - '0 " ` SAN JOAQUIN Environmental Health Department COUNTY Gr,�LiLi cLs� y;-oivs het : 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 Ham Lane City/State/Zip Lodi, CA 95240 Phone 800-511-9300 Cross Street Lockeford Street APN 037-100-300 Property Owner* Stone Bros & Assoc Phone 800-511-9300 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 Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 61 ®BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA ® SOILVAPOR PROBE 4 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER I'bing ❑ SOIL BORING J❑ PUSH POINT(GP/CPT) CONDUCTOR CASING [I Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH 41 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 Portland Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: 7 U ' 7 viA_ ( li vy�.L'� i�t.N��'�"1f "?%1" 'f- +'.L�►tit 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 Z�)al !/ Title/Company Senior Geologist Print Name Daniel Villanueva Date 06/23/2025 I Application Accepted By: DEPARTMENT USE ONLYDate Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name T ��,t . ; �� !� FA Addressr, �. al wt FA# PR# FA PE WP Reviewed By Work Plan Date q 2 ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement lead Agency Approval ❑MFR COMMENTS/CONDITIONS: it 5 \) � ) [�Or WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $172 x .% J (�L r l L`tl� / R2500 91 4123 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 Site Mitigation Well Permit Application