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DocuSign Envelope ID: 74C24ACD-5589-4C30-8FAC-E39439F495EB "f('"c° SAN JOAQUIN p Environmental Health Department 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 1958 S El Dorado St. City/StateiZip Stockton, CA 95206 Phone NA Cross Street GOT St. APN 167-042-12 Property Owner* City of Stockton Phone 209-937-8411 Address 22 E.Webber Ave. Rm301 City/state/Zip Stockton, CA 95215 C-57 Contractor Middle Earth Geotestina License# 899451 6 � 3 2625 Phone 714-633-5025 Address 23575 Chabot Blvd CltylState/Zip Hayward, CA 94545 Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831-464-1634 Address 1336 Brommer St. Ste.A6 CltylState/Zip Santa Cruz, CA 95062 CONSTRUCTION WORK TO BE PERFORMED: *Note: O(tsile BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 80' ❑BOLTEOTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vap&M'ater) ❑ HAMMERNWVEN DIA.OF BOREHOLE 98• ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER I4 SOILSORING —TO PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Die: Casing Dia: Casing Depth: ❑ INJECTION(Airspaae.Ozone) 0 HANDAUGER GROUT SEAL DEPTH TREMIETYPETO BE USED: ❑AUGERS ❑HOSE WNPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? in Yes ❑No (Note:Maximum Freefall Depth)Is 30 Ft) WELD SOIL BORING IDS HP2 GROUT SPECIFICATIONS Neat Cement 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 El EXPLOSIVES From_to_feet below surface R TY TO BE USED AUGERS [I HOSE PIPE HR99 et pw surface or feet below surface if>3 feet MMENTS: ter—, vnce je�,;. nc �y re (a �► a S P� WR 5 sc,,m i, ereby certify that I am authorized to comple t I p ftntion nd-that-the-wor I I be one In accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Print Name Date PA ENT USE ONLY r� Application Accepted By: Date Issued: / 2 o Grout Inspection By/Dates: \ 2�L Destruction Inspection By/Dates: Facilit /Site Information FAName i k� FAAddress qo o FA# ©Q PR# d �9 FA PE WP Reviewed By Work Plan Date j. 4Z ❑C-57 7Authorization for Other to Sign Permit ❑Workers Comp ❑Wadkers Comp Waiv ❑ ment Permit ❑AcoessAgreement ❑Lead AgencyApproval MFR COMMENTS/ ON�DnITIONS: rt , U,. ( _ C // �o Y� c `x` .3'Crf ' r-YL pn n wa WP TYPE I�PE SC? FEE INFO AMT REMITTED CHECK`# RECV'D BY DATE 1 ,� IWpE�LvL,PERMIT# INVOICE* —d Permit 2-I 6 ' 31J 3. •T X I I �-. C- W W q- 93 1868 E. Hazelton Avenue I Stockton, California 95205 4 T 209 468-3420 F 209 464-0138 wow. jX kd.c6m EHD 29-01 04-20-23 /` V% 3 6^C'O'g 3 CIO z D+\ Site Mitigation well Permit Appliraaon j CC I 686 /)