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S A N J O A Q U I N Environmental Health Department —COUNTY ter•.'''' Care❑[n ss rTrnrvs 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 andlor 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 North Ham Lane City/statelzip Lodi, CA 95252 Phone Cross Street West Lockeford Street APN 037-10-030 Property Owner' Stone Brothers & Associates (John Go di) Phone 209-200•-8506 Address 103E West Robinhood Drive, Suite 202 city/state¢ip Stockton, CA 95207 C-57 contractor Environmental Control Associates (ECA)License# 695970 Phone 831-662-8178 Address 3011 Twin Palms Drive citylStatelzip Aptos, CA 95003 Consultant/Sub-Contractor ► License# Phan Address /Statelzip �LL -L0 �,► ,Y\ CONSTRUCTION WORK TO BE PERFORMED.*Note: Offsfte HaringsivVeBs Require Access Agreements or Encroachment Permits wd 0 ) ] TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f ❑ MONIToRING ❑ HOLLOW STEM BORING DEPTH 50'(2)&15'[2) ❑BOLTED TRAFFIC BOX 0 STOVE PIPE ❑ EXTRACTION(Vapor)Water) ❑ HAMMEFIIORIVEN DIA.OF BOREHDLE 2r' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA �[SOILVAPORPROBE 471 MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑OTHER [SOIL BORING 4[A PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring DIa: Casing Div. Casing Deplh: ❑ INJECTION fNr suawoza"I ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No �Nolw Maximum F4eefall Depth Is N A) WELLISOIL BORING IDs B —B GROUTSPECiF1CAT1oN5 Neat cement grout vil0tremmie;w_ elllsail vapor probe sand nacklegulpment will be r8moved before grouting 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 helowsurface TREMIE TYPE TO UE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that I am authorized to cam pi ate 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.' Title/Company Project ManagerlPaltner Engineering&Science, Inc. Print Name Michel Helou Date 5/5/2023 j DEPARTMENT USE ONLY Application Accepted By: /'_ �' Date Issued: Z;4a 4 Grout Inspection By/Dates: Destruction Inspection BylDates: Facllit /Site Information FA Name �� r-k11 Lt'(? f4�'i FA Address �. �1 t + FA# r` f' �- PR# FA PE C� / wP Reviewed By ,� Work Plan Date ❑G57 Aulhorizaporr for Other to Slgn Permit ❑Worker's Comp 11 Warker's Comp Waiver ❑Encroachmenl Permit O.AcressAgreemeal ❑ Agency Approval AMFI1 C COMMENTSfEOND1TIQNS: : }ry 1 ,✓!r yt �� 1 C Y ?rr c r .,i { Mil !� A,-. .r ro t.t W c�L' o rir+-�..� 1 1Y I r �w r�r� + �lT) [11'w' ��j G�` ' �1��. •, �+�P �[.w�ti•i�� WP TYPE PE Sc FEE INFO AMT REMIT TED CHECK# RECV'D BY D TE . WELL PERMIT* INVOICE# Permit C'lL� 5�7 $156x L �, •_ r 3 6 -1 L Z 1868 E. Hazelton Avenue l Stockton, California 95205 l T 209 468-3420 l F 209 464-0138 l www.sjcehd.com EHD2MI 04-2o-23 `1 C _ + _�1 ✓F L f '� Site MIuganon Wall PermkAppllcation