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i <br /> SAN a <br /> Environmental Health Department <br /> COUNTY <br /> Greatness 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 2546 French Camp Turnpike City/State/Zip Stockton.CA95206 Phone 905-564-1077 <br /> Cross Street Buena Vida court APN 165-261-260-000;165-261-250-000 <br /> Property Owner* Pride Group Enterprises(French Camp Holding Corp) Phone 905-564.1077 <br /> Address 1100 Brickell Bay Dr,#310747 City/State/Zip Miami,FL 33231 <br /> C-57 Contractor En Probe License# 1012248 Phone 530-693-0219 <br /> Address POBox6093 City/State/Zip Oroville,CA95966 <br /> Consultant/Sub-Contractor Blew Inc. License# Phone 925-299-1465 <br /> Address 3825N Shiloh or City/State/Zip Fayetteville,AR 72703 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 n bgs ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ® SOIL VAPOR PROBE 7 ❑ MUD ROTARY CASING THICKNESS�TYPE OF CASING: ❑STEEL❑PVC §1 OTHER - v► <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes u rvu boring Dia: Casing Dia: asing Depth: <br /> ❑ INJECTION(Air Sparge,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATION�fi'aI cemer�t� <br /> DESTRUCTION WORK TO BE PERFORMED: CTION ME OD: CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED ❑OVER-BORE IAMETER of inches to depth of feet <br /> WELL IDs GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: T. OL .G� (�tw DUL 6c 4N44 S i L. OV.�'1'�Y fG>'L�,� E �V-out yL•y_ �iJ <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 xt4;ig L?�7 Title/Company.Project Geologist,Blew Inc. <br /> Print Name Ahk Denning Date 10/20/2025 <br /> DEPARTMENT USE ONLY <br /> + i / <br /> Application Accepted By: /��Ls Date Issued: 11 I 1 l 7 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: AAL4U4 Z S ,00U10`L5 <br /> Facility/Site Information <br /> FA Name (.)4(, ji/,�y�vL `� FA Address 2�H�, n Ll , f ( A# 0 0 bl: 0 <br /> FA PE WP Reviewed By Work Plan Date <br /> IgC-57 -&R-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Aaiver ❑Encroachment Permit ❑Access Agreement Wead Agency Approval 0 MFR <br /> COMMENTS/CONDITIONS: � \ S 0 C S Co ,ri -n v-c 1 L,;, -,,( li cl(at-1 y <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# REC 'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 7h P)� 3I � $179 x -� ,3 ' "{/ 'I'D 1161 7� 250Z—//i 2.1 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 4 t) 0 I F 209 464-0138 ( www.sjcehd.com <br /> EHD 29-0107-01-2025 Z! 0,?3 Fi Site Mitigation Well Permit Application <br />