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/°U11V 68 <br /> - c°,2 SA N J OAQ U I N Environmental Health Department <br /> COU NTY - <br /> A/L,FO �% 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 12025 West Hazelton Ave City/State/Zip Stockton CA 95203 1 Phone 13046139635 <br /> Cross Street Is Ventura Ave APN 145-030-060 <br /> Property Owner* Norcal Materials,Inc. Phone 8178354105 <br /> Address 331 North Main Street City/State/Zip Euless,TX 76039 <br /> C-57 Contractor I GreggDrilling,LLC License# 11044456 1 Phone 19253135800 <br /> Address 12100 Good ear Road City/State/Zip I Benicia,CA 94510 <br /> Consultant/Sub-Contractor 1jacobs License# INA I Phone 3046139635 <br /> Address 2705 Bee Caves Rd City/State/Zip jAu.tin,TX 78746 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 6 f b s ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 14 in 1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> 8 SOIL BORING 24 ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Sparge,Ozone) N HAND AUGER GROUT SEAL DEPTH i&' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Fre fall Depth is 30 Ft) <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS INLr k- C-L' <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE []PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> S Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company I Environmental Scientist/Jacobs <br /> Print Name tt Loughney Date 5/15/2026 Ma <br /> (J DEPARTMENT USE ONLY i <br /> Application Accepted By: �J --• Date Issued: t lZf' <br /> Grout Inspection By/Dates: �y <br /> Destruction Inspection By/Dates: /I(} <br /> Facility/Site Information <br /> FA Name �l •�— V• FA Address p �.�u ((�.1 FA# PR# <br /> FA PE WP Reviewed By Work Plan Date 7 <br /> ❑G57 -57 Authorization for Other to Sign Permit orker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit cress Agreement ad Agency Approval E+INFR <br /> COMMENTS/CONDITIONS: Z� �oi IL ty> N�y� I'_r 5 Vk <br /> WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2 U7 ��3 $179 x C :220837190, Z b iP 7L0 ) <br /> 220835567 ) t� L-G' <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 07-01-2025 Site Mitigation Well Permit Application <br />