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`QLIM- <br /> 2'� SANA0A0UIN Environmental Health Department <br /> —COUNTY— <br /> Greatness grows h <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 Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 1951 S. El Dorado St City/State/Zip Stockton, CA 95206 Phone N/A <br /> Cross Street Howard St APN 165-080-61 <br /> 209-937-8411 <br /> Property Owner* City of Stockton Phone <br /> Address 22 E. Webber Ave, Room 301 City/State/ZipStockton, CA 95215 <br /> C-57 Contractor Middle Earth Geotesting License# 899451 Phone 714-633-5025 <br /> Address 23575 Chabot Blvd City/State/Zip Hayward, CA 94545 <br /> ConsultanUSub-Contractor FREY Environmental, Inc License# 643673 Phone 831-464-1634 <br /> Address 1336 Brommer Street, Suite A6 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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 60' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 2.5" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOILBORING 1 PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE t IPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? 0 Yes ❑No.(Note:Maximum Freefall Depth is 3,0 Ft) <br /> WELU SOIL BORING IDs HP3 GROUT SPECIFICATIONS�o)/t %Tl <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑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 /> __.Sail Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 7tL=_3 Title/Company Project Manager <br /> Print Name Terrence Kinn Date 12/10/24 <br /> DEPARTMENT USE ONLY j <br /> Application Accepted By: �,c� Date Issued: 17,E l�L Z <br /> Grout Inspection By/Dates: I �5 I uy�— / <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information _ <br /> FA Name r G "uU `I/FU'�- FA Address ro �; w�� S FA# ( I PR# <br /> FA PE WP Reviewed By �p�}- Work Plan Date <br /> ❑C-57 *-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑ o is Comp Waiver ❑Encroachment Permit ❑Access Agreement Lead Agency Approval MFR <br /> COMMENTS/CONDITIONS: / i\ Yi> <br /> WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit D `S l $172 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-2024 i K:2 b7 b C"VSite Mitigation Well Permit Application <br /> Vt,a J-64 —+ <br />