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SANdOAQUIN Environmental Health Department —COUNTY— ('I"'oCO 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 9-1116.3, and the San Joaquin County Well Standards. Job Address 234 E 4lh St. City/State/Zip Stockton,CA 95206 Phone NA Cross Street San Joaquin St APN 167-043-04 Properly Owner' City of Stockton Phone 209-937-8411 Address 22 E.Webber Ave. Rm301 City/StatelZlp Stockton,CA 95215 C-57 Contractor Environmental Control Associates License# 695970 Phone 530-441-8393 Address 3011 Twin Palms Drive City/State/Zip Aptos,CA 95003 Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831-464-1634 Address 1336 Brommer St.Ste.A6 City/State/Zip Santa Cruz, CA 95062 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offslte BodngsANells Require Access Agreements or Encroachment Permits TYPE OF WELUBORINO NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _ M MONITORING 1 fJ HOLLOW STEM BORING DEPTH I 0 BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXIRACTION(VaporAVater) ❑ HAMMERNRIVEN DIA.OFBOREHOLE R. ❑MULTIPLE CASI NOS❑MULTbUEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS 0.154' TYPE OFCASING: ❑STEEL ®PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONWCTORCASING ❑Yes (ANo Baing Dia: 8' Casing Dia: 2' Gazing Depth: 106 ❑ INJECTION uospxmo. ❑ HAND AUGER GROUT SEAL DEPTH TREMIETYPETOBE USED: ❑AUGERS ❑HOSE UPIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ONO (Note:Maximum Freelal Depth is 30 FQ WEWSOILBOFUNGIDs MW-16 GROUT SPECIFICATIONS Neal Cement DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED [I OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑PRESSUREGROUT To depth of feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From_to—feet below surface TREMIE TYPE TO BE USED [I AUGERS [I HOSE ❑L PIPE 1 ❑MUSHROOM CAP ❑3 feel below surface or feet below surface If>3 feel COMMENTS: SCrek¢ 1.ij ^ In51JS`, 15,aA, ] z - *f '4 .3C rQeN , RA-{,Ell -s� .z-,gl flw,f . Cwj �Mck, [emo,n� �CSr.+'-t�" ,-f'Fanf ra„ �'o �O Per Wor+0/ vN I hereby certify that 1 am authorized to complete this application and that the work will he done 10n ccordane' with - San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Manager FREY Environmental, Inc. Print Name errence Inn Date:2023.09.1113:54:13-07'00'Date 9/11/23 D PARTMENT USE ONLY /I I / (] �� Application Accepted By: D la Issued: Grout Inspection By/Dates: 144 Destruction Inspection By/Dates: Facilit /Site Information �1 �rr� (� FANama i it r ()U FA Address V r FA# Vv�4�-1 PR# rjZf'80 S,-11 FA PE Zq GO WP Reviewed By -� '6� Work Plan Date j `0 ❑C57 7Au0wdzae9n lorONerMSign Permit ❑Wodcera Comp ❑Workers Comp Waive ❑E men/Pe t ❑ Agreement AgencyApproyd FR COMMENTSICONDITIOI�S:Mt,Lsr o b-(� 0 0. 1 1'eF�.t�. t om' C r'f y �'fv�tC 111� 4✓oCA Ftr41;4-s WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit orb 133sllty r — I - 1-3 ICC, I 1W (VI I z3 00 83 S1,-00gT'I�--Z 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD29-0104-20-23 C( 16 V 6S 24 r/— Site Mitigation WON PerMI AppOwtion