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SAN jOAQUIN COUNTY" 4 ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sioov.org/ehd UNIT IV WELL PERMIT APPLICATION 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 San Joaquin County Environmental Health Department. Assessor's Well Location_ 12751 N.Thornton Rd Cross Street _ Interstate 5 City _Lodi Zip 95242 Parcel# 055-130-16 Property Owner_City of Lodi Address _ 1313 South Ham Lane_ City__Lodi Zip_95240 _Phone# (209)333-6706 C-57 Contractor Gregg Drilling&Testing Address _950 Howe Rd — City Martinez Lic# -48516 Phone. (925)313-5800_ Consultant/Sub CntrStantec Consulting Address_3017 Kilgore Rd Ste 100 _ city Rancho Cordova Lic# 654498 Phone_(916)861-0400 _ GIS Coordinates:X.6306742.51 _ ,Y -2219663.77 ,Township Range Section 25 WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) [SOIL BORING#_24 [--]OVER-BOREDIAMETER ❑WELL# ❑ PRESSURE GROUT ❑-OTHER GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIF CATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z'S M MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE .PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIM FREE-FALL.Q(EI IS 30') ❑SOIL BORING 39HANDAUGER GROUT SPECIFICATIONS �J O��Z I.LIM�W1 ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YE&list soedfcationsm oommentseaion) COMMENTS:_shallow sample depths and H&S requirements may preclude or limit use of mechanical drillinq equipment NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS _1 hereby_certify-thatl have-prepared-this-application-and-that-the-work-will be-done-I-accordance with-San Joaquin County Ordinances,Rules and Regulations,and all appl/ic�.(ple California Laws. Signed IfL'ne �j Title/Company Geologic Project SpecialisUStantec Print Name Lary Braybrool s Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 12.1 k d DY.W� WORK PLAN DATED: 9 APPLICATION ACCEPTED BY DAT ISSUE AREA,,G� GROUT INSPECTION BY FINAL INSPECTION 6 :� DATE v-7 DESTRUCTION INSPECTION BY DATE L COMM E NTSICON DITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE -will SR# - C-57,�- WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT Z ENCROACHMENT DOC EHD 29-01 111510](WEB) WELL PERMIT APP