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SAN ..JOAQU I N ron mental Health Department COUNT Y— r- .�r-ctness grows her;:. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (269) 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 135 E. Miner St City/State/Zip Stockton, CA 95202 Phone (209) 465-6810 Cross Street N. Hunter St APN 139-080-10 Property Owner* Juan Ruvalcaba + '4 O-A Phone same as above Address 135 E. Miner St City/State/Zip Stockton, CA 95202 C-57 Contractor Middle Earth Geotesting License# 899451 Phone 714/633-5025 Address 23575 Chabot Blvd City/State2ip Hayward, CA 94545 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: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ER MONITORING ❑ HOLLOW STEM BORING DEPTH 100 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ® SOIL BORING 2_® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes R1 No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Spann,Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: [IAUGERS ❑HOSE ®PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Rl Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/ BORING IDs CPT1, CPT2 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 ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑ HOSE ❑PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: I hereby certify that 1 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. Signed Title/Company FRE_Y_ _Environmental. Inc. Digitally signed by Terrence Kinn Print Name Terrence Ki n n Mte•9099 11 01 11.17•49-07'00' Date DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: )2 Z Facilit /Site Information FA Name = FA Address 3 / ; FA# )U PR# 9-' 8 Vol FA PE O WP Reviewed By s Work Plan Date 6 2� ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: -r Gpl" p eS r t'YL W 0 /10 dQS r� ; 4- >� E?�,/►C A 0 � � Oct n . , w A fe er ► V-5 i' V2r► y -�►'�'►f�►I 9 �o�'t 'I"U b�-ow� ) of A d ►M t?� ►gct"tb 4 ceou- us-t' - �� W . St�br�r�c�y r�sul-� r �r wQll WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Q 2 Permit 2 1©� ✓� $152x 1868 E. Hazelton Avenue I Stockton, Caiifornfa 5205 T 209 468-3420 1 F 209 464-0138 1 WWW.Sjcehd.com EHD 29-01 04-04-07 - 1 '5 z Z S b 4 ? Site Mitigation Well Permit Application y- -ft 1 5Z�� Lt- erg, r