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SAN JOAQUIN Environmental Health Department COUNTY `?1' 11v0 '� GreoIness grolys hrrp. 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 3230 Ng West Lane City/State/Zip Stocklm.CA95206 Phone Cross Street EAlpine Ave APN 117-080-17 Property Owner' Gdcheh Developments and lnveslments LLC Phone (310)804-7970 Address 1180 S Beverly Drive,Suite 300 City/State/Zip Los Angeles,CA 90035 C-57 Contractor Gregg Drillirw LLC License# C-5711044455 Phone (925)313-6800 Address 950 Howe Road City/State/Zip Mardnez.CA 94553 ConsultantlSub-Contractor Smnlec Consuldm License# Phone (949)637-1543 Address 38 Techmlogy Drive City/State/Zip Irvine,CA 9261E CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsWells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 40 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VapoeWaler) ❑ HAMMERDRIVEN DIA.OF BOREHOLE 2.5Imh ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 10 SOILBORING 5 ® PUSH POINT(GP/CPT) CONDUCTORGASING [I Yes [I No Boring Dia: Casing Dla: - Casing Depth: ❑ INJECTION M suave.0zonel ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [I AUGERS [I HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Madmum Freefail Depth is 30 FQ WELU SOIL BORING IDS SB-1,S62,SB-3,SB-4,SB-5 GROUT SPECIFICATIONS Neat cemmn ntonke gout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel WELL Me ❑PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel 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 . e Title/Company Engineer-Smntec Consulting Print Name Hdly Quasern Date 7/612023 PARTMENT USE ONLY , L / Application Accepted By: Date Issued: �? "L- / Z0 Grout Inspection By/Dates: Destruction Inspection By/Dates: �1 Facilil /Site Information FAName - — /Q✓.( _ — FAAddress 1 FA# © © ' PR# FA PE 261 5 WP Reviewed By � Work Plan Date �-- 20 0057 G-57AuthonzaGm fer Other to Sign Permit ❑Workefs Comp ❑Wodmrs Comp Waiver ❑CEncroaachmmentnPermit ❑Access Agreement ❑Lead Agency Approval FR COMMENTIS/I SI�T7I/O'�N�S�:A r y�e-C,,d+5 WP TYPE PE SC F E INFO AMT REMITTED CHECK# I RECV'D B D TE WELL PERMIT# INVOICE# Permit iiip s X - ��D2(� ry�s �D 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 4g94-0138 1 V Wkec�11 .corn EHO 29-01 04-20-23 6 4 q C1 (+ O/ /'L— 16gSite Mitigation Well Penult Appli.Uon I b 5 q-5-