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i Docd5ign Envelope ID: 873F4A1D-7EC6-4F23-AB32-1COCFE316ED5 SANdOAQUIN Environmental Health Department —COUNTY \�gcrFoa�`P 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 324 N. Hunter St. City/StatelZlp Stockton . CA Phone (209)465-6810 Cross Street East Miner Ave. APN 139-140-17 Property Owner' Enterprise Car Rental Phone 209 465-6810 Address 324 N. Hunter St. City/StatelZlp Stockton, CA C-57 Contractor Middle Earth Geotesting License# 899451 JI , O 24hone 714 633-5025 Address 23575 Chabot Blvd. City/State/Zip Hayward, CA 94545 ConsultantlSub-Contractor FREY Environmental, Inc. License# 643673 Phone 831 464-1634 Address 1336 Brommer Ts., Ste.A6 City/StatelZlp Santa Cruz, CA 95062 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsile Bodngs/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH too ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXrRACTION(VapwM'ater) D HAMMER1DRIVEN DA.OF BOREHOLE 25 ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS NA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER El SOILBORING 1 © PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ®No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sozme.0zon0 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: [I AUGERS [I HOSE ElPIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 91Yes ❑No (Note:Maximum Freefall Depth is 30 FQ WELL/SOIL BORING IN HP3A 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 feel below surface GROUT SPECIFICATIONS El EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED El AUGERS [--] HOSE [I PIPE El MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feel COMMENTS: hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joa In Ca�yD7ty Ordinance Codes and Standards, and all other applicable California laws. Signed — V� Title/Company FREY Environmental, Inc. Print Name Avery Sullivan Date ENT USE ONLY Application Accepted By: Dale Issued: I �� Grout Inspection By/Dates: o 1 Destruction Inspection By/Dales: 6G�" . cap 206.y Facilil /Site Information FAName I FAAddress 1 5 M I PRO FA PE WP Reviewed By Work Plan Date r 2 l� SDI t/y 0 C-57 57Authodzagon for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ead AgeiwyAppmval MFR i/ COMMENTSIC NDITIONS: 7 M ✓✓u-e, cOpn okr o� i/ns c1lti/nV-IfinQ rncfwdl'K — Y-,V-0— +f . WP TYPE PE SC I FEE INFO JAMT REygTTEDj CHECK# I REC 'D BY DATE WELL PERMITYt INVOICE# Permit S I -74 5182x 2 II WF 04j3 cc I S1200X?10 . 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.$)cehd.com EHD 29-01 7-01-2M3 Site Midgaron wall Permit Application