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Pa�'h SAN JOAQUIN COUNTY IGINA"" �+ ENVIRONMENTAL HEALTH DEPARTNItNT LOP N' `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION CqC/FOR �P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.orq/ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Standards of the San Joaquin County Environmental Health Department. Site Location keQt/Rimby Ave Cross Street Hutchins Street City/State Lodi,CA Zip Z-y APN City Streets Property owner City of Lodi Address 221 West Pine Street PO Box 3006 City/State Lodi,CA Zip 15141 Phone 209-333-6706 C-57 Contractor Gregg Drilling Address 950 Howe Road City/Staten Z Lic 9H 553 Phone C1 7-5'-1313 -s$� Consultant/Sub Cntr Applied Water Resources Address 1600 Riviera Ave Suite 310 City/State w""'Cr-k,CA Lic�h Phone �ZS"H Z(o- 1 1 Z Billable Party Applied Water Resources Address 1600 Riviera Ave Suite 310 City/State W,11 creek,CA zip q L4S--q-iy Phone 925-426-1112 GIS Coordinates:X_3$. IZDZ(Q0 Y -121. 2�g�jp 3$. 11 toSg9 ) - 111. 2-7924to* R. PArK SAcee+ ^�by CONSTRUCTION WORK TO BE PERFORMED: ❑0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) 0 SOIL BORING IDs 0 H WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / SMONITORING ❑HOLLOW STEM DIA OF BOREHOLE 8 O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _O EXTRACTION:Vapor/Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑ PVC O OTHER ❑SOIL VAPOR PROBE [9 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE O PIPE ZOO SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: OO Yes ❑ No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION(i.e.Air Soaroe,Ozone)❑ HAND AUGER GROUT SPECIFICATIONS Nec,� C e(y\t-Ok /1)W g 5 f Allo-rd S OTHER: ❑OTHER: APPROX.BORING DEPTH 250-300' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No O Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and all applicable California laws. w9 Q, �(� Signed Title/Company /� Co cp Print Nam ff- !Adlick E!n y(Wy\ Date Lt 2- -1 I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 4ob t 6bLc<wr- f Lumz WORK PLAN DATED R 12 APPLICATION ACCEPTED BY O P9Kur DATE ISS A GROUT INSPECTION BY FINAL INSPECTION BY r..... nArE 3-2q-14/ DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE Q REQUESTG PR# ;490 t $125 x 1 f.C> SR# zqo� 3� Roo) / ZgO� 17.5 ` i2 (2s 0) C-57 v WC ✓ WAIVER 4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT !/ ENCROACHMENT DOC A— FHD 29-01 5/09/12 WFI I PFRMIT APP