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2:PnUTA* VANd0AQUIN p <br /> Environmental Health Department <br /> COUNTY <br /> OFoaa� 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 J aquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> C Gad (�uv� NA <br /> Job Address 204 E Sixth St {irr�keet) City/State/Zip Stockton,CA 50206 Phone <br /> Cross Street S.Hunter St APN 167-103-02 (p5 J'Ljw <br /> Property Owner* City of Stockton Phone 209/937-8411 <br /> Address 22 E.Webber Ave City/State/Zip Stockton,CA 95215 <br /> C-57 Contractor Environmental Control Associates License# 695970 Phone 530/441-8393 <br /> Address 3011 Twin Palms Dr City/State/Zip Aptos,CA 95003 <br /> Consultant/Sub-Contractor FREY Environmental,Inc. License# 643673 Phone 831/464-1634 <br /> Address 1336 Brommer St.A-6 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 /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Suame,ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 1 ®OVER-BORE DIAMETER of 8_inches to depth of 77 feet <br /> WELL IDs MW-17 ❑PRESSURE GROUT To depth of 77 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement 6 gals water per 94 Ibs of cement ❑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 Regional Manager <br /> Print Name Terrence Kinn Date 6/11/26 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: It 7,6 <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information <br /> FA Name t l�Rref t tip FA Address l °jp 5� 1%( �ca.� FA# — PR# 4 �•, <br /> FA PE WP Reviewed By Work Plan Date �- <br /> ❑C-57 V C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver QdIncroachment Permit ❑Access Agreement Kh-ad 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 v], '/ � $179 x I, 222z5oso2 <br /> ( f 222193809 t <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 07-01-2025 Site Mitigation Well Permit Application <br />