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° = SA N.-J OAQ U I N Environmental Health Department <br /> —COUNTY— <br /> Greitness crows 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 Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address 1901 S.El Dorado St City/State/Zip Stockton,CA 50206 Phone NA <br /> Cross Street Fifth St ApN 165-080-19 <br /> Property Owner' Sharma Family Trust Phone 510/825-5251 <br /> Address 33215 Falcon Drive City/State/Zip Fremont,CA 94555 <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 /> ConsultanVSub-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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN 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 Swrue.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ff 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 16 ®OVER-BORE DIAMETER of 8&10 inches to depth of 40-105 feet <br /> WELL IDs MW1-MW4,MW6-MW10,EW1-EW3 and VW1-VW4 ❑x PRESSURE GROUT To depth of 40-105 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 n HOSE ®PIPE E&MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: 0 D'. rK r2rf- D4.-. Zc ;�� <br /> ✓,. �1w r t t r � � <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: <br /> Destruction Inspection By/Dates: 7 'J 1 Zv -ST t Wr Gv <br /> Facilit /Site Information V&ft 31 <br /> FA Name j�H G4,tj (] t�v FA Address "(V 1 5 I -a�� FA# PR# <br /> FA PE ZG1�t7 WP Reviewed By Work Plan Date <br /> ❑C-57 PC-57 Authorization for Other to Sign Permit Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement E}Lead Agency Approval AD MFR <br /> COMMENTS/CONDITIONS: C �) IV l lLU-1 ,,, ( fw1 <br /> WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> I -'­ 222250602 J 1 <br /> Permit1,0� L $179 xjJ yt� 222193809 b`(� ��'��/n <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 07-01-2025 Site Mitigation Well Permit Application <br />