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.PQU)y C R I G "i N A' .�oG SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP :< 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • �,'�• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web.www.sigov.orq/ehd 4�/Foa WELL & BORING PERMIT APPLICATION EB 12 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL {EAL.TH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. �Ct1VYl�lita Site Location Q kS*- ross Street Hutchins Street City/State Lodi,CA Zip APN C r�y Property Owner City of Lodi Address 221 West Pine Street PO Box 3006 City/State Lodi,CA Zip Phone 209-333-6706 C-57 Contractor Gregg Drilling Address 950 Howe Road City/State Martinez,CA Lic 1/85/6j Phone Consultant/Sub Cntr Applied Water Resources Address 1600 Riviera Ave Suite 310 City/State Wa'"°'Creek,CA Lic Phone Billable Party Applied Water Resources Address 1600 Riviera Ave Suite 310 City/State Wal"°'Creek,CA Zip Phone 925-426-1112 GIS Coordinates:X $.Q0Iko0Y - 17-188ZO - Pa(►L t*tQ12 3g. lt(o3990� -121. Z�g2ye��.Rmby CONSTRUCTION WORK TO BE PERFORMED: Al NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS j i ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑� MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS N MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Z TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑O MUD ROTARY DEPTH OF GROUT SEAL VaCZ OQ. z TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:JAI Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —E]INJECTION(i e.AirSoaroe Ozone)❑HAND AUGER GROUT SPECIFICATIONS D W R Vye�\ ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Z5 O–300 99 BOLTED TRAFFIC BOX OR ❑STOVE PIPE e ONDUCTOR CASING m No El Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: P fasQ See Gam,c''emAyx, X W21k COt1S}C�Lt�0A 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. /� p ^^ Signed �— Title/Company Tll/�1, C OcIJ Print Name U /ta hRNCAM Date Z--4- 1y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS wO DI - !�' UFA/T 1 ALCti"CC WORK PLAN DATED F f !s 6 It / 2c I APPLICATION ACCEPTED BY DATE ISS GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION B DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PRq# Q $ 125 x I I QouR�r ,� - -/ SR# C{U 1 `Q 3 R3 00 PR# 2900 C-57 WC V, WAIVER jt2ll— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 1% ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP