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S A NJ Q A Q U I N Environmental Health Department <br /> COUN I Y <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For INSPECTIONS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 135 E. Miner St City/State/Zip Stockton,CA 95202 Phone (209)465-6810 <br /> Cross Street N. Hunter St APN 139-080-10 <br /> Property Owner* Juan Ruvalcaba Phone same as above <br /> Address 135 E.Miner St City/State/Zip Stockton,CA 95202 <br /> C-57 Contractor Middle Earth Geotesting License# 899451 Phone 714/633-5025 <br /> Address 23575 Chabot Blvd City/State2ip Hayward,CA 94545 <br /> Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831-464-1634 <br /> Address 1336 Brommer St.Ste.A6 City/State/Zip Santa Cruz,CA 95062 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> E$ MONITORING ❑ HOLLOW STEM BORING DEPTH 100 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2.5 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOIL BORING 2 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: <br /> ElINJECTION(Air Sparge,Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE t2 PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/ BORING IDs CPTI,CPT2 GROUT SPECIFICATIONS Neat Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed Title/Company FREY Environmental,Inc. <br /> Digitally signed by Terrence Kinn <br /> Print Name Terrence Kinn Oata•�ro�llmirn-4a-m'nn' Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />