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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ke 600 East Main Street,Stockton,CA 95202-3029 SITE MITIGATION <br /> Telephone:(209)468-3454 Fax.,(209)468-3433 Web:www.sIjqOV.OEg1ehd <br /> UNIT IV— <br /> WELL BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> t(o"EFUND6gLE PERM IT EXPI89§1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor Install the work described. This application Is made In compliance with Son <br /> Joaquin County Develooment Tide_Chaptei^-"^ -1—--—-..---- - - - nty Environmental Health DepeArneM. <br /> Lodi city Landfill Mokelumne River Drive&Awani Drive Lodi ZIF 95240 APN 041-410 <br /> Site Location Cross shoe --- Uffy— — <br /> Prop" City of Lodi 221 West Pine Street Lodi (209)333-6801 <br /> Owner— Address citv—. --. Zip__L5240 Phon, <br /> C-67 Contractor Address city- -Ijc Phone. <br /> j Moore 5710 Ruffin Road — city _Lic Phone (858)576-1000 <br /> ConsultantfSub Cntr Njnyo jin( )dress - San Diego <br /> Billable Party Address CRY—Zip_Phone__ <br /> GIS Coordinates:X <br /> 38.14875 -121.27025, <br /> �R SEE ATTACHED SHEETS <br /> 01STRIlf 9—NW -KTQ-IEPERFgRMLD <br /> EI NEW WELL1801RING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs <br /> Vj WELL IDs r VC, 77, <br /> 0 OTHER iDs <br /> jXPj&f OF WELUMN43 INI&LAT12MMM goWUCIW SPECIFSOM <br /> MONITORING ®HOLLOW STEM DIA.OF BOREHOU Vy C3 MULTIPLE CASINGS 0 MULTKEVEL WELL CASING OW: <br /> [3 EX rRACTIONt V%W Water E3 KAMMERIDRMN CASING THICKNESS fc tj -TYPE OF CASING: 0 STEEL P PVC 0 OTHER <br /> .LC,E]SOL VAPOR PROBE C3 MUD ROTARY DIM OF GROUT SEAL TREMtE TYPE TO BE USED: [3 AUGERS 0 HOSE [34IPE <br /> SOIL BORING [3 PUSH POINT(GP!CPT) GROUT SEAL PUMPED,C)Yes[3 Na(MAXIMUM rRF E FALL DEPTH IS 30 FT) <br /> INJECTION U,&,Va=X2M11 Z3 HAND AUGER GROUT SPECIFICATIONS-®Bentonite <br /> P BOLTED TRAFFIC BOX OR 13 STOVE'IPE <br /> SEE <br /> OTHER: OTHER-_�. APPROX BORING DEPTH— -- <br /> SEE A17ACHED SHEETS 0ONDUCTOR CASING 0 No 0 YOW Cal"DID: Ca*V DePft—Wr9 DID;— <br /> COMMEM* <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> AEEW <br /> DESTRUCTION WORK TOBEPERFORMED: DE3MUG33ON METHQD;(CHECK ALL THAT <br /> #OF WELL(s)To BE DESTROYED [I OVER-BORE DIAMETER OF INCHES TO DEPTH OF <br /> FT <br /> WELL lDs: <br /> 0 PRESSURE GROUT To DEPTH OF FT BELOW SuuACE GROUT SPECIFICATIONS 0 EXPLOSIVES FROM To_FTBELOWSURFACE <br /> [3 MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> TREMIE TYPE To BE USED:YU AUGERS E)HOSE 0 PIPE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby codify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances.Rules and <br /> Regulations,and all applicable California Laws, <br /> Signed Title/Company Date <br /> Print Nam <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT TV FILE SITE ADDRESS <br /> WORK PLAN DATED DATE ISSUED AREA__ <br /> APPLICATION ACCEPTED BY FINAL INSPECTION BY DATE <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDMONS: <br /> ACCOUNTING ONLY: AID# FAC 0 <br /> SERVICE IRO I INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> SR# <br /> RO# <br /> 3500 <br /> PR <br /> PR# <br /> C-57— WC_WAIVER G57 LETTER OF AUTHORIZATION ENCROACHMENT Doc— <br />