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th SAN .IOAQUIN COUNTY ORIGlM r : ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV a 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 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 7091 E Live Oak Road Cross Street Angier City/State Lodi,CA Zip 95240 APN 061-160-06 Property Kurt and Sandra Kautz Owner Address 5490 Bear Creek Road City/State Lodi,CA Zip 95240 phone (209)368-3113 C-57 Contractor Woodward Drilling Address PO Box 336 City/State Rio Visa.CA Lic 710079 Phone (707)374-4300 ConsuManVSub Cntr Fall Creeek Engr Address PO Box 7834 city/State Seale C"'?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 CONSTRUC11ON WORK TO BE PERFORMED: ®NEW WELLISORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MW-30 OTHER IDS TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING IN HOLLOW STEM DIA.OF BOREHOLE 8 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 Inch _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS SCh 40 TYPE OF CASING. ❑STEEL M PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 95 TREMIE TYPE TO BE USED: KI AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ^❑INJECTION(i a AaSoeroe_Ozmel❑HAND AUGER GROUT SPECIFICATIONS Neat Cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH_ 120 feet ❑BOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASING i(4 No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) *OF WELL(S)TO BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE El PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby em"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 ap ble Cal ornia aws. Signed Title/Company �/1 �� N Q�-✓ Rt �N Print Name to DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE I/-+l GROUT INSPECTION BY FINAL INSPECTION BY . One x" DATE 10-?-IV DESTRUCTION INSPECTION BY DATE COMMENTSICO N DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR* 10-7 $PZ5 X Vi 6k �r Gl�3�l SR# 0a(7q-11 /1 /4}7�. (2 RO 0 3500 PR* 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHM rTI\/CCI\/ � END 29-01 5/09/12 omtc PEk KM-Y+ffP SEP - 3 2014 SAN JOAQUI'N COUNTY ENVIRONM NTAL HEALTH DEP TMENT