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,0,.?4�,F.co� SAN .JOAQUIN COUNTY <br /> ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> to: < <br /> • 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> SITE MITIGATION <br /> Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV <br /> '�C f F ORS <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 40 N. Main St. Cross Street E.Oak St.&E.Pine St. City/State Lodi/CA Zip 95240 APN city right-of-way <br /> Property Cit of Lodi 221 W.Pine Street Lodi/CA 95240 209-333-6800 <br /> Owner Y Address City/State Zip Phone <br /> C57 Contractor PeneCore Drilling Address 220 North East Street City/State Woodland/CA Lic 906899 phone 530-661-3600 <br /> Consultant/SubCntr E2C Remediation Address 5300 Woodmere Drive,Ste. 105 City/State BakersfieldicA Lic 72685 phone 661-831-6906 <br /> Billable Party City of Lodi Address 221 W.Pine Street City/State Lodi/CA Zip 95219Ab -333-6800 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: FEB 2 8 2014 <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs ' ifeA611:11 IN OU <br /> ❑WELL IDs E......+....�.r=u <br /> ❑OTHER IDs MI BEPm,9+ 111199 <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DFS.TRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> - #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF or 10 INCHES TO DEPTH OF 3 FT <br /> WELL IDs: see attached page with the list of wells to be destroyed PRESSURE GROUT TO DEPTH oFwell casing depttFT BELOW SURFACE <br /> GROUT SPECIFICATIONS neat-cement grout ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS HOSE ■PIPE MUSHROOM CAP AT L3 FT) 3 FT BELOW SURFACE <br /> COMMENTS see attached"Site Decommissioning Workplan"for destruction method details <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regul �l ap _ California laws. <br /> Signed Title/Company L� /CII(J" <br /> Print Name 1E'✓ E-r Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �lD Al • M I ti <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED B�( , � DATE,ISS / AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY ATE 7w- J1�/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M E NTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �b r 3621 SIR#Xb8m;?4�516 <br /> 2go3 �.�d ytiz5 i� Z �� (3500) <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />