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!_ �ZSKJOAQUIN Environmental Health Department ILn ` COUNTY Greatness grows her, 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 826 North California Street and 517 East Flora Street City/State/Zip Stockton,CA 95202 Phone 209-468-0310 Cross Street East Flora Street and North Amencan Street APN 139-175-180-000 and 139-175-120-000 Property Owner* County of San Joaquin Phone 209-468-0310 Address 44 North San Joaquin Street City/State/Zip Stockton,CA 95202 C-57 Contractor AdvancedGeo,Inc License# 1063765 Phone 800-511-9300 Address 837 Shaw Road City/State/Zip Stockton,CA 95215 Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA N/A ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N/A ® SOIL Boring 2 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soaroe.Ozonel ❑ HAND AUGER GROUT SEAL DEPTH 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 69 and B10 GROUT SPECIFICATIONS Portland Type II. 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 [IAUGERS [:]HOSE ElPIPE [IMUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: 1-.pr("Jpk�r w r,C�.�;r� '• (.0� Z�r7d L� O See work plan dated 08-20-2025 I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San)JJoaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed /I/�Q/2, Title/Company AdvancedGeo Inc Print Name Maxwell Niemeyer Date 08/20/2025 DEPARTMENT USE ONLY / Application Accepted By: � Date Issued: Lz� Lz Grout Inspection By/Dates: �jq / �(lG( ��M �V. Destruction Inspection By/Dates: Facili /Site Information —1 FA Name V Si;V�ov L�p,vh �u+� AAddress FA# b,1 t Ol� PR# �� 15 FA PE t] WP Reviewed By Z��cl °�`� Work Plan Date T L 2 ❑C-57 ❑G57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: (Z 7 S U �'' S 4'� 6)-- 00-4-Vl >rf I L{i WP TYPE PE SC I FEE INFO JAMT REMITTEDI CHECK# CV'D BY I DATE WELL PERMIT# INVOICE# Permit 2°cP �"; Is'-4x 2 1 tv U - �l�C�5, wpa5msmaq 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 2Q9 46� 34 0 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-2024 2,, �(, 1 2 Site Mitigation Well Permit Application