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1. AN :J OAO U IN Environmental Health Department iT i -_ - G(DUNTY--- till„.�,,,��' c;reolnzs5 grnlvs lirrt 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 applicatiog is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address 1 110 East Turner Road City/StatelZip Lodi,CA 95240 phone Not Applicable Cross Street Stockton Street APN 041-24µ050 at WSee attached Figure 1. Property owner* Lustre-Cal LLC c/o Joe Hohenrider Phone (925)876-6263 Address 13481 Forest Park Circle City/State/zip Penn Valley,CA 95946 C-57 Contractor Penecore Drilling License# 906899 Phone (530)661-3600 Address 220 North East Street City/State/Zip woodland,CA 95766 ConsultantlSub-Contractor Stephen G.Muir Consulting Geologist License# CEG 91224 Phone (209)601-6694 Address Pa Box 152 citylstatelzip Woodbridge CA 95258 CONSTRUCTION WORK TO BE PERFORMED:*Note; Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIQ0 ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15 feet 00 BOLTED TRAFFIC BOX ❑STOVE PIPE I] EXTRACTION(VaporlWaier) �® HAMMERORIVEN DIA,OF BOREHOLE n e-S❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 00 SOIL VAPOR PROBE 12 ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL 0 PVC Ij OTHER ❑ SOIL BORING ❑ PUSH POINT(GP!CPT) CONDUCTOR CASING [3 Yes X No Boring DIa: Casing Dka: Casing Dap1h: ❑ INJECTION(Air Soame.ozone} �❑ HAND AUGER GROUT SEAL DEPTH 13 and 5,5 feet TREMI£TYPE TO BE USED- ❑AUGERS I]HOSE 2 PIPE ❑ OTHER p OTHER: GROUT SEAL PUMPED? O Yes 0Q No (Note;Maxlmum Freefali Depth Is 30 F1) WELL!SOIL BORING IDs LC 1-12 GROUT SPECIFICATIONS Hydrated bentonite at two depth zones for temporary Installation Please see attached Figure 2 for proposed soil vapor probe locations and Figure 3 dual zone sail gas well completion diagram. DESTRUCTION WORK TO BF,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 feel below surface TREMIE TYPE TO BE USED ©AUGERS L]HOSE Ij PIPE MUStiROOM CAP ❑3 feel below surface of feet below surface if 73 feet COMMENT$:Prease see attached loiter from RWQCB approving wgtkplen.Attached Figure S shows proposed completion of dual zone sail gas walls.The soil gas wells will be completed as semi-pgrmangnt with$.deal teaf6cboKes.Grout to be used will be hydrated bentonite.we propose to chill and install 14.5 foot deep soil gas probe tip In each well followed by placement of hydrated bentoahe ft r the deep ran a followed byInstallatlonof7.0foot soil gas probe tip.Upper zone will not have hydrated b4ntonhe grout lnstalledurall.SJCEFI111nsvea0eIs posona.Surface eompletlonwill Include installation of steel traffic box.All son gas wglis wilt hsoverdrllled after sail gas Invastrgation It completed under separate permit with SJCEHD. I hereby certify that 1 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 - 1y1 Title/Company. e~?4c sJ . Mv t n Aj sr z-n6Lrr_ ,,c,_` Print Name Date / ZO - _ DEPARTMENT USE ONLY + Application Accepted By: 1 Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Sillp.Information FA Name �.Lt£, f,..L� C'„A'k FA Address I l LTV V'-� t FAY i%C �V PR# L FA PE r { , WP Reviewed By Work Plan Date ❑C-57 ❑C,57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Camp aivar ❑Encroachment Permll ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTSICONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# i Permit 3 t u i `r t $179 x 5 �r� S — el -a 1) J� 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 466-3420 i F 209 464-0138 1 www.sjcehd.com EHO 29-01 07-01-2025 site Millgation well Permit Appllceyop