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tQ <br /> ui <br /> SAN JOAQUIN COUNTY <br /> —ter ' ENVIRONMENTAL HEALTH DEPARTMENT � LOP <br /> co: < <br /> '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •.- ;P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:ww .sigov.orCl/ehd UNIT IV <br /> w <br /> �IFOR� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 40 N.Main St. Cross Street E.Oak St.&E.Pine St. City/State Lodi/CA Zip 95240 APN city right-of-way <br /> Property Cit of Lodi 221 W.Pine street Lodi/CA 95240 209-333-6800 <br /> Owner Y Address City/State Zip Phone <br /> C-57 Contractor PeneCore Drilling Address 220 North East Street City/State Woodland/CA Lic 906899 Phone 530-661-3600 <br /> Consuftant/SubCntr E2C Remediation Address 5300 Woodmere Drive,Ste.105 City/State Bakersfield/CA Lic 72685 Phone 661-831-6906 <br /> Billable Party City of Lodi Address 221 W.Pine Street City/State Lodi/CA Zip 952 9-333-6800 <br /> an r ri-� <br /> GIS Coordinates:X Y RECEIVED <br /> CONSTRUCTION WORK TO BE PERFORMED: _ S 2014 <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs ���+■++ <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINW❑%&A WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CAMs® a$"EEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYw TO eE USED Q AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FWE FALL OEF'TH M 30 FT) <br /> _❑INJECTION f e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _• <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH l]&MITT '>i{ rIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia:___Ca"Oqr. Boring Dia: <br /> COMMENTS: — <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR EWROACHIMIrMT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHO1Y aeEM <br /> 7-:_#OF WELLS)TO BE DESTROYED N OVER-BORE DIAMETER O> W- L TO DEPTH OF 3 FT <br /> WELL IDs: see attached page with the list of wells to be destroyed ®PRESSURE GROUT TO L>EPTH OF WW morm depth=T BELOW SURFACE <br /> GROUT SPECIFICATIONS neat-cement grout ❑EXPLOSIVES FROM TO_ FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS HOSE ®PIPE N MUSHROOM CAPAT L _ FT BELOW SURFACE <br /> COMMENTS see attached"Site Decommissioning Mrk()ian"for destruction method details <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with&an Josav+-+Cou-ity Ordinances,Rules and <br /> Regul �I.app California laws. <br /> Signed Title/Company <br /> Print Name Er Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS �rD N • M IV <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BL DATE ISSUED / AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M E NTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICERO# INVOICE <br /> REQUEST PR ll <br /> 2 TO Z- s 125 X Q2 �r 5-d b . "'834 <br /> 36 zi SR# g$S Z-'4 -5yU <br /> 2go3 -.DD y9 5 / RO# <br /> 3500 <br /> PR# �� <br /> 2900 <br /> 75 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 5/09/12 WELL PERMIT APP <br />