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i oPQU-IY c� SANAOAQUIN Environmental Health Department " A 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 600 N. Main St. City/State/zip Manteca, CA, 95336 Phone 209-649.3"0/669.777-6616 Cross Street E. Edison St. APN 223-141-17 Property Owner* Sav-In Management, LLC; Indra and Savitri Yadav Phone 209-649-3440/669-777-8616 Address 3462 Rutherford Drive City/State/zlp Stockton, CA, 95212 C-57 Contractor Penecore Drilling;Project Manager:Xavier Green License# 906899 Phone 530-661-3600 Address 220 N. East Street city/State/zip Woodland, CA, 95776 Consultant/Sub-contractor AECOM Technical Services Inc License# Phone 805-297-0637 Address 2020 L Street, Suite 300 City/State/Zip Sacramento, CA, 95811 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 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSoarae.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE I IPE t-C ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No_(Note:Maximum Fre Depth is 30 Ft) WELL/SOIL BORING IDs _-_GROUT SPECIFICATIONS_ DESTRUCTION WORK TO BE PERFORMED: DESTR THOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 7 ®OVER BORE DIAMETER of 2.25" inches to depth of 15 feet WELL IDs SG-1,SG-2,SG-3,SG-4,SG-5,SG-6,SG-7 ESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS Grout to surface with neat cement ❑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 �j San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed 4U)6l Title/Company AECOM Print Name Paul Sugimoto Date 11/25/2025 DEPARTMENT USE ONLY Application Accepted By: Date Issued: i L L z- ' Grout Inspection By/Dates: Destruction Inspection By/Dates: �L � 2V Facili /Site Information FA Name 0 dj 5 p FA Address k 00 iu, wC FA# PR# �y 4 FA PE q WP Reviewed By Work Plan Date I :L 57 ❑C-57 Authorization for Other to Sign Permit 9 Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement -Wead Agency Approval %bFR COMMENTS/CONDITIONS: rt:, F2'Z 5-V v"I WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RE V'D BY DATE WELL PERMIT# INVOICE# Permit $179x LI L} (z W P 0-501 3J 1868 E. Hazelton Avenue 1 Stockton, California 952051 T 209^�468-3420 (�F 209 464-0138 1 www.sjcehd.com EHD 29-0107-01-2025 Z L t vq/� �-. Site Mitigation Well Permit Application