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,OP,r?UI%v SAN4,�QQQQ � N Environmental Health Department COUNTY 4c , �/tl 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 234 E Fourth St (+ra streei) City/State/Zip Stockton,CA 50206 Phone NA Cross Street S.Hunter St APN 167-043-04 , Property Owner* City of Stockton Phone 2091937-8411 Address 22 E.Webber Ave City/State/Zip Stockton,CA 95215 C-57 Contractor Environmental Control Associates License# 695970 Phone 530/441-8393 Address 3011 Twin Palms Dr City/State/Zip Aptos,CA 95003 Consultant/Sub-Contractor FREY Environmental, Inc. License# 643673 Phone 831/464-1634 Address 1336 Brommer St.A-6 City/State/Zip Santa Cruz,CA 95062 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 1 ❑OVER-BORE DIAMETER of 8_inches to depth of 105 feet WELL IDs MW-16 PRESSURE GROUT To depth of 105 feet below surface GROUT SPECIFICATIONS Neat Cement(6 gals water per 94 Ibs of cement ❑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 I 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 Regional Manager Print Name Terrence Kinn Date 6/11/26 _ DEPARTMENT USE ONLY I Application Accepted By: Date Issued: b\( )' l Z Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name c71K� �� ln � FA Address l� p� �( t7Jca�,� FA# — PR# L�-4Vr,,,3S FA PE ( iJ 1 WP Reviewed By Work Plan Date r" ❑C-57 1j]l C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver PaEncroachment Permit ❑Access Agreement ead Agency Approval M MFR COMMENTS/CONDITIONS: ` $ WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PER^M7ITT# INVOICE# Permit V2 j( j $179x 'k 222193eos 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 1 www.sjcehd.com EHD 29-01 07-01-2025 Site Mitigation Well Permit Application