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SAN JOAQUIN Environmental Health Department COUNTY Greatness grows here. 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 125 East Lodi Avenue City/State/Zip Lodi,California 95240 Phone (916)261-6194 Cross Street South Stockton Street APN 043-063-080-000 Property Owner* OLSON,REX IN TRUST Phone (916)261-6194 Address 478 Sandstone Court City/State/Zip Woodbridge,CA 95258 C-57 Contractor AdvancedGeo,Inc License# 1063765 Phone 209-373-2708 Address 837 Shaw Road City/State/Zip Stockton,California 95215 Consultant/Sub-Contractor AdvancedGeo,Inc License# 1063765 Phone 209-373-2708 Address 837 Shaw Road City/State/Zip Stockton,California 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 15 ft ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE InC e�❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 11—[3(PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Some.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑IV (�Note:Maximum Freefall Depth is Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS 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: 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 0Lj 4L, Title/Company AdvancedGeo,Inc. Print Name MaXWell iemeyer Date August2o2o24 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name s m �I-� FA Address 1 , FA# PR# FA PE WP Reviewed By C Work Plan Date � 1d C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's 2sp Waiver ❑Encroach nt Permit ❑Access Agreement ❑ ad Agency Approval ��ow ' COMM ENTS/CONDITIQNS: �2 Q — & T'K . T .9,rA+m C a1v Ic'-,xv JA)d/ WP TYPE PE SC FEE-NFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit ZfD $172x (ZDLt � Z P Z�QD t � $� O.ZO SR Z�oo 'fi� f� 1868 E. Hazelton Avenue I Stockton, California 95 05 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 7-01-2023 Site Mitigation Well Permit Application