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"r`A"' SANJOAQUIN Environmental Health Department COUNTY- - "4rh'! Greatness govrs herd. ,,o 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 2461 North Wilson Way City/State/Zip Stockton, CA 95205 Phone N/A Cross Street Robindale Avenue APN 11707053 Property Owner* Restomod Properties LLC Phone N/A Address 4601 Greenoals Lane City/State/Zip Stocicton, CA 95212 C-57 Contractor Environmental Control Associates License# 695970 Phone 831-662-8178 Address 3011 Twin Palms Drive City/State/Zip Aptos, CA 95003 Consultant/Sub-Contractor AEI Consultants License# 654919 Phone 937-829-9031 Address 2500 Camino Diablo City/State/Zip Walnut Creels, CA 94597 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 2-10', 2-5' ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.25" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA [K SOIL VAPOR PROBE 4❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSaarge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [] HOSE PIPE ElOTHER OTHER: Direct PusbGROUT SEAL PUMPED? ❑Yes ElNo (Note:Maximum Freefall Depth is 30 Ft) WELU SOIL BORING IDs SB-1, SB-2, SB-3, 0 4 GROUT SPECIFICATIONS Neatcementgrout DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED N/A "fOVER-BORE DIAMETER of ', ' inches to depth of 10 feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS yr;.{yb El EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE 21 PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: 'pit vtl Ev � �f,►riVU'� �tr� ll 4 1�Y'Ccjv-g' 71.t� i'vlr � �5�,�� l—i ��. , .r�ro\ S 1' S\C� (,�l,l•t `i4—;:t,lM' -�'�� I ,: -. I hereby certify thatI am authorized to completethis 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 Staff Scientist/AEI Consultants Print Name Madison Kennedy Date 11/20/2024 DEPARTMENT USE ONLY Application Accepted By: , Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑ G57 ❑ C-57Authorization for Other to Sign Permit ❑ Worker's Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement ❑ Lead Agency Approval ❑ MFR COMMENTS/CONDITIONS: j�l 1i; Y'Y"vl� `� h�L �S WP TYPE PE SC I FEE INFO JAMT REMITTED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $172x 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjce EHD 29-01 08-01-2024 VA,6/0 i I •I ) � +/ ' . Site Mitigation Well Permit Application