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SAN JOAQUIN Environmental Health Department ---COUNTY— �hh,_„_ ' Greutness grows It(!i 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 235 E 61h St City/State/Zip Stockton,CA 95206 Phone NA Cross Street San Joaquin St APN 167-044-12 - - Property Owner' - City of Stockton Phone 209-937-8411 Address 22 E.Webber Ave. Rm301 City/StatelZip Stockton,CA 95215 C-57 Contractor Environmental Control Associates License# 695970 Phone 530-441-8393 Address 3011 Twin Palms Drive CIlylStat01Zlp Aotos.CA 95003 Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831-464-1634 Address 1336 Brommer St.Ste.A6 Clty/StatelZip Santa Cmz,CA 95062 CONSTRUCTION WORK TO BE PERFORMED:*Note: ONsile BodngsAVells Require Access Agreements or Encroachment Perils TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS M MONITORING . I G9 HOLLOW STEM BORING DEPTH W M BOLTED TRAFFIC BOX ❑STOVEPIPE ❑ EXTRACTION(Vapa/Waler) ❑ HAMMERJDRIVEN DIA.OF BOREHOLE W ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASINGTHICKNESS 0,154' TYPEOF CASING: [I STEEL ®PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT( CONDUCTORCASING [I Yes INNo Boring Die: W Casing Dia: Y Caskhg Depth: W ❑ INJECTION(Alrtoraa.Omnel ❑ HANDAUGER GROUTSEALDEPTH TREMIETYPETO BE USER. []AUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER GROUTSEALPUMPED? ®Yes El No (Hole:Mattoon Freitag Depth Is30F6 WEWSOIL BORING IDS MW-17 GROUT SPECIFICATIONS NeatOement 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 To depth of feet below sodace GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED [I AUGERS Q HOSE.[]PIPE [I MUSHROOM CAP ❑3 feel below sdaw or Teel below surf ace if>3 feet COMMENTS:.r rwv\- 40 Se j Scl.+l - �� Ct eVC SCr�t1A rlNs, %cl'1 b ark(-e 1'c' ,(4d{e sand pkck, Ce n'�� E►�hs�flo� see Fo sar C.e rc�rn , 2 I hereby certify that I am authorized to c plate this application and that the work will be done in accordance With �Cr, �/ayf San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. a qt 1 Signed 1119itallyTitle/Company Manager-FREY Environmental, Inc. Print Name errence Kinn Date:2023.09.11 13:52:50-07'00' Date Off 1/23 ,_ tom , DEPARTMENT USE ONLY (� /lrT Application Accepted By: Y�/- gg Date Issued: _I /I I / -2 o Grout Inspection By/Dates. c Destruction Inspection BylDales: Facllit /Site Information n 2 FA Name C U i r t D FA Address 0 ' Tj r' U FA# d(�z'f �'� PR# OE5 FA PE WP Reviewed By �L,J Work Plan Date 1 ❑G57 7Avthorizaton faOBmr to Sign Permit ❑Workers Comp ❑Wakeescomp Walver E LlPem4 ❑A Agreement A Approval R COMMENTS/CONDITIONS:N\v s i, 1- .�-G1 h g1 2 �-Qej(-ttt ,l, --mc_ awoctcmd 400ollite IWPTYPEI PE I Sc I FEE INFO JAMT REmgT-rr:Dj CHECK#I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit 12 o I I 313 s16ZK 1 '5 1 D,43 I CC 1123 WOO 3o . 1}eh 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 WWW. 1CJ.com 129,0104-20-23 CC I / A /_ S �(LI3L Site Mitigation Wer Permt Appticaton