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4 ' DocuSign Envelope ID: 873F4A1D-7EC6-4F23-AB32-1COCFE316ED5 SANcT10AQUIN n Environmental Health Department tee, —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 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 244 N. Hunter St. City/State/Zip Stockton , CA Phone (209) 465-6810 Cross Street East Miner Ave. APN sidewalk in front of 139-130-28 Property Owner' City of Stockton Phone Address CitylStatelZip Stockton,CA C-57 Contractor Middle Earth Geotesting License# 899451 W e G Z j Phone 714 633-5025 Address 23575 Chabot Blvd. CitylStatelZip Hayward, CA 94545 Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831 464-1634 Address 1336 Brommer Ts., Ste. A6 Clly/Stato/Zip Santa Cruz, CA 95062 CONSTRUCTION WORK TO BE PERFORMED: `Note: Offate BodngsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH 100 ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ FXTRACTION(vapormaler) ❑ RAMMERIDRIVEN DW.OF BOREHOLE 2.5 ❑MULTIPLE CASINGS MULTELEVELWELL CASING CIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASINGTHICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING 1 © PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ©No Bodng Dia: Casing D1a: Casing Depth: ❑ INJECTION fPiaoaae.owne) D HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS OTIOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? El Yes ❑No (Note:Maximum Freefall Depth is 30 FQ WELL/SOIL BORING IDS HP4 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 Ds .[I PRESSURE GROUT To depth offeet below surface GROUT SPECIFICATIONS [I EXPLOSIVES From to feel below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below 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 JoajWIn Co ty Ordinance Codes and Standards, and all other applicable California laws. Signed � � Title/Company FREY Environmental, Inc. Print Name Avery Sullivan Date DEPA TMENT USE ONLY I 20 Application Accepted By: VS I Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: A&t vet 7 — 7- 1-q Facili /Site Information 2 FA NameIt UL�FA Address FA# V Z J q PH# 0 FA PE `L WP Reviewed By Work Plan Date ill L'Z 4' SAT 0G57 k5=1 Authwintion for Oliver to Sign Permit ❑workelsscanp ❑Wodcers Comp Waiver oachr�meeJWPermit ❑Ac�cessAAgeement Lead AgencyAppoval FR 41 COMMENTSI N TIONS:� lb�l�(' rE✓5 �1� S ''� . Z �s ,r�i- Covtr Iko il Lai Ixis .(-/w ♦S1>r2 ;Wk4"1;VI dttvz PTYPEJ PE I SC I FEE INFO AMT R MITTED CK# RECV'DErYj DATE WELL PE IT# INVOICE# Permit12�0 $162 x C (1 Z(f VJP� - 3 1868 E. Hazelton Avenue I Stockton California 92 5 1 T�09 468-3420 1 F 209 464 0138 www�.sjce hd.com EHD 29,017-01-2023 Site Mitigation Wall Permit Application