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SAN JOAQUIN Environmental Health Department -----C O U N T Y--- (.�Ie.otness o10v"s 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 101 West Lathrop Road City/State/Zip Lathrop, CA 95330 phone N/A Cross Street Old Harlan Road APN 196-080-700-000 Property Owner* * Cardoza FamilyTrust (Edward Cardoza) Phone 209-531-6801 Address 2604 East Lovelace Road City/State/Zip Manteca, CA 95336 C-57ContractorBa] a Exploration License# 804318 Phone 760-743-7678 Address 1915 Commercial Street City/State/Zip Escondido, CA 92029 Consultant/Sub-Contractor Partner Erigineering & Science, Inc. License# N/A Phone 7 7 4—414—3 6 6 6 Address 490 43rd Street City/State/Zip Oalcland, CA 94609 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 5' (5) &=0 ' (3) ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 611 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 6 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE ❑PIPE El OTHER 2 perc test borings❑ OTHER: GROUTSEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B1—B6 and P1 & P2 GROUT SPECIFICATIONS Neat cement grout via tremmie; well/soil vapor probe sand pack will be removed before aroutina 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 El3 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 Title/Company Project Manager/Partner Print Name Michel Helou Date 9/10/2024 DEPARTMENT USE ONLY 7 Application Accepted By: ` / �' Date Issued: / Grout Inspection By/Dates:,. /�I Destruction Inspection By/Dates: "b 12429 Facilit /Site Information v FA Name 7jSb�� FA Address r bvil Zar4-h FA# t PR# FA PE l? ,�( } - WP Reviewed By �'^ .'� - Work Plan Date t f � i!" ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: tio t LMM % It � �Ii `cil C L�AA C; 1- vil\kl t,J ' 44 i r v } ' i Y" Y l�l i' 11 k l s i WP TYPE PE FEE INFO AMT RE ITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit ;j, j $172 x 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F�209 464-0138 1 www.sjcehd.com t EHD 29-01 08-01-2024 Site igdt(On Well Permit Application