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DocuSign Envelope ID: 74C24ACD-5589-4C30-8FAC-E39439F495EB SANJOAQUIN 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 andfor 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 234 E 4th St. CitylState/Zip Stockton, CA 95206 Phone NA Cross Street San Joaquin St APN 167-043-04 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 Geotestino License# 899451 1 Phone 714-6335025 Address 23575 Chabot Blvd City/SlatelZip Hayward CA 94545 Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831464-1634 Address 1336 Brommer St. Ste.A6 City/State/Zip Santa Cruz, CA 95062 CONSTRUCTION WORK TO BE PERFORMED: *Note: Oftsite Bofings/Welis Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 120' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWaler) ❑ RAMMERNWVEN DIA.OF BOREHOLE 251 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER N SOILBORING ❑ PUSH POINr(GP/CPT) CONDUCTOR CASING ❑Yes [I No ruling Dla: Casmij Dia: CNIng Depth: ❑ INJECTION(Aieoarae.ozone) D HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ElYes ❑No (Note:Maximum Freefall Depth is 30 Fit WELUSOIL BORING IDS HP1 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 feel WELL IDs ❑PRESSUREGROUT Todepthof feetbelowsudam GROUT SPECIFICATIONS ❑EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet belay 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. �� Digitally signed by Title/Company Signed Te Pint Name Terrence Inn Date Inn AR MENT USE ONLY n ' ' e P ^ V20 Application Accepted By: Date Issued: `•'r G Grout Inspection By/Dates: 'V -(,A`L Destruction Inspection By/Dates: Facility/Site Informationvt /7 FA Name I'll C {�n l L r' U FA Address 00 FA# � PR# G J a FA PE C) WP Reviewed By Work Plan Daleley �p ,6 /2 2 111G57 G57 Authorization fixOtherlo Sign Permit ❑Workers Comp ❑Workers Comp Waiver ment Permit ❑AocessAgreemenl ❑Lead Agency Approval FIR COMMENTSICON TIONS: , p nA v") o r ' � ►--Ie- y WP TYPE I PE I SC I FEEINFO jAMTREmiTTEDj CHECK# I RECWD1BY DATE WELL PERMIT# INVOICE# Permit q_ 3 ff Z< I1 J 'a CC �w 1 I c 1868 E. Hazelton Avenue I Stockton, California 95201 1 T 209 468-3420 1 F 209 464-0138 1 'www.sjcehd.com EHD29-0104-20-23 C 6 pS ` n 74 ('y,Zlitipatipn� Well Permit Appliraeon