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SAN JOAQUIN COUNTY *40010 IN � <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ar <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> .- ;p• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd UNIT IV <br /> q�l�oae+ <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—Lodi/GA Zip Phone--- <br /> C-57 Contractor PeneCore Drilling Address 220 North East Street City/State Woodland/CA Lic 906899 Phone 530-661-3600 <br /> Consultant/SubCntr E2C Remediation Address 5300 Woodmere Drive,Ste. 105 CitylState Bakersfield/CA Lic 72685 phone 661-831-6906 <br /> Billable Party City of Lodi Address 221 W.Pine Street City/State Lodi/CA Zip 95240 Phone 209-333-6800 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs _. <br /> ❑WELL IDs — <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑PAULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i e.Air Sparse Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> Qj Q� ­2f #OF WELLS)TO BE DESTROYED [I OVER-BORE DIAMETER OF8 or 10 INCHES TO DEPTH OF 3 FT <br /> WELL IDs: see attached page with the list of wells to be destroyed Q PRESSURE GROUT TO DEPTH oFwell casing deptl'FT BELOW SURFACE <br /> GROUT SPECIFICATIONS neat-cement grout ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS HOSE © PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS see attached"Site DecommissioningWorkolan"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 San Joaquin County Ordinances,Rules and <br /> Regulation d Tapp I Califomia laws. <br /> Signed ` Title/Company <br /> rl <br /> Print Name ( 1 G'V/ C_=f— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED ` III 7iUl3 <br /> APPLICATION ACCEPTED BY ���5{�i!�III P�i� DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PggR# <br /> `b 125 x%'/)L) )700 SR# 80� <br /> RO# <br /> z q 03 ()U (3500) <br /> PR# U� <br /> �7 7 2900 U <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 />