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1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com <br />ECEIVED <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION JUN 2 3 2017 <br />For Wells and Borings Used for Contaminant Investigations and Remediatali/pIREROmNMITEIsNETRALvIcHNLTH <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. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 54 North Cluff Avenue City/State/Zip Lodi, CA 95240 <br />crossstreet Mounce Street APN 049-050-57 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />Date Issued: k7 Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />*-0-3i-c1SD <br />Property Owner* John Estrada - Meo.PaA( <br />Address 54 North Cluff Avenue City/State/Zip Lodi, CA 95240 <br />Consultant/Sub-Contractor Partner Engineering and science, Inc License# NA Phone (510)410-1009 <br />Address 1017 22nd Ave, Suite 107 City/State/Zip Oakland, CA 94606 <br />Favi eit/1,i-- mc-0-k uv\ <br />SAN JOAQUIN COUNTY — <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />Associates, Inc. License# C-57 #695970 <br />City/State/Zip ivael+1.--zetr-ey5-2-4-0. 1117AAvi PatvA5 ttv <br />Akos cA 15-003 <br />Phone (209) 603-931+ <br />Phone (209) 603-9317 <br />(831) 662-8179 Phone <br />TYPE OF WELUBORING NUMBER <br />ID MONITORING 0 <br />0 EXTRACTION (VaporNVater) 0 <br />0 SOIL VAPOR PROBE 0 <br />2 SOIL BORING 6 0 <br />0 INJECTION (Air Soave. Ozone) 0 <br />0 OTHER 2 <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: Direct- <br />Push <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 1 5 ft bgs 0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE 2.5 in. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS TYPE OF CASING: 0 STEEL ED PVC 0 OTHER <br />CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />Bl, 32, 33, 34, B5, B6 <br />COMMENTS: 6 borings to 15 feet below ground surface and deconstruct the same day with neat <br />cement. Soil sampling only using geoprobe direct-push rig <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />(rNs. Title/Company -PG, e-frt•Id,{ 4„vtd emt,e, Tot,. <br />DEPARTMENT USE ONLY <br />FA Name 'A ' 411- 'f"4;\i'l 41-1..-C1 r‘nA44.'r FA Address Y4 14,--11-FA# PR# p_s-Li te, Li a <br />FA PE ,Xcl.S1) WP Reviewed By C., Work Plan Date <br />k--,, / 2;1- i I 7 <br />0 C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br />Permit 1,0),•/ c 3 1 3 $139x 3 $ 41-7 til-sC"- <br />3 fc/ o 1---- )( ilia li --) s 113E-r3 <br />Signed <br />Print Name marv 0 ( ravi-vve,- Date 1, /2- V/ 14- <br />C-57 Contractor Environmental Control <br />Address (831) 662-8178 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> 0 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />0 EXPLOSIVES From to feet below surface <br />MUSHROOM CAP 0 3feet below surface or feet below surface if >3 feet <br />e LiO3 C2 13cpt <br />EHD 29-01 10-26-2015 <br />-ill 110,1 <br />36vty Site Mitigation Well Permit Application