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� ORIGINAL SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATIONUNIT IV Telephone: (209)468-3147 Fax:(209)468-3433 Web. www.sigov.org/ehd 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 worts 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 12050 N Curry Avenue Cross Street Armstrong City/State Lodi,CA Zip 95240 APN 061-150-14 Property owner Goldstone Land Co. LLC Address 11900 N Furry Road City/State Lodi,CA Zip 95240 Phone (209)368-3113 C-57 Contractor Woodward Drilling Address PO Box 336 City/State Ft'0vva.CA Lic 710079 Phone (707)374-4300 Consuttant/Sub Cntr Fall Creeek Engr Address PO Box 7834 City/State ten.1 CfW CA Lic 55605 Phone (831)426-1440 Billable Party Bear Creek Winery Address 11900 N Furry Road City/State Lodi, CA Zip 95240 Phone (209)368-3113 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: Z]NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MW-4D ❑OTHER IDs TYPE&#OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING I@ HOLLOW STEM DIA.OF BOREHOLE 8 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 Inch _❑EXTRACTION:Vapor/water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 95 TREMIE TYPE TO BE USED: HI AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:21 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(1 a Air Soame Ozo)el❑HAND AUGER GROUT SPECIFICATIONS Neat cement _❑OTHER: ❑OTHER: APPROX-BORING DEPTH 120 feet ❑BOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASING 60 No❑Yes:Casing Dia: Casing Depth: Bonog Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:/CHECK ALL THAT APPLY) 1 *OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: MW-4 ®PRESSURE GROUT TO DEPTH OF 100 feat FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES FROM TOFTBELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS N HOSE ❑PIPE ®MUSHROOM CAP AT(>3 FT) 3eld t 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 ap7Fe�rickaA�kc Signed Title/Comparry Civil Engineer Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATAREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE SERVICE RO* INVOICE REQUEST PR* 0 s; x 1 t7 SA- L q� ), SR# 60 11IV/9 b3 Mti 6'i.02)4 s 500 U2 /3vX f / X 0.4q-4,26,- iso PAYmEtITI C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHM iVED EHD 29-01 5/09/12 S,N1�LL PERMIT 014 SAN�JOAQU13t1 20UNTY ENVIR0NME AL HEALTH DEPA{q E TNtENT