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City/State/Zip Lodi/ CA/ 95240 Phone N/A APN N/A - drilling location in right of way SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation 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 San Joaquin County Well Standards. W Tokay between South Church and S School & Intersection of W Spruce and S School Streets Property Owner* City of Lodi ... _ . Phone 209-333-6878 Address 2001 West Turner Road City/State/Zip Lodi, CA. 95240 C-57 Contractor CPT Inc. License# 884827 Phone 510-357-3677 Job Address Cross Street Address 820 Aladdin Avenue City/State/Zip San Leandro, CA, 94577 Consultant/Sub-Contractor Langan Engineering and Environmental LIcense# Phone 510-874-7041 Address 501 14th Street, 3rd Floor City/State/Zip Oakland, CA, 94612 CONSTRUCTION WORK TO BE PERFORMED: *Note: Of/site Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING El MONITORING EXTRACTION (Vapor/Water) SOIL VAPOR PROBE El SOIL BORING INJECTION (Ak saaro. °zombi CI OTHER NUMBER INSTALLATION TYPE o HOLLOW STEM CI HAMMER/DRIVEN 0 MUD ROTARY 2 1:K1 PUSH POINT (GP/ CPT) 0 HAND AUGER OTHER: WEW SOIL BORING IDs CPT-1, and CPT-2 CONSTRUCTION SPECIFICATIONS BORING DEPTH 120-150 feet 0 BOLTED TRAFFIC BOX 0 STOVE PIPE DIA. OF BOREHOLE • 1 75 indies 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER CONDUCTOR CASING 0 Yes 0 No Boring Dix: Casing Dia: Casing Depth: GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE D PIPE GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED 2 DESTRUCTION METHOD: (CHECK ALL THAT APPLY). El OVER-BORE DIAMETER of inches to depth of feel WELL IDs CPT-1, and CPT-2 E PRESSURE GROUT To depth of S feet below surface GROUT SPECIFICATIONS 94 lb Type ll Portland to 5 gallons of clean water. 0 EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE E PIPE IKI MUSHROOM CAP 03 feet below surface or feet below surface if >3 feet COMMENTS' Scope of work: Conduct two CPT soundings to depths of 120-150 feet using 30-ton CPT rig. In adjacent borings, collect a water sample. Hand auger all locations to five feet bgs. Backfill test location (s) by tremie grouting to surface and mushroom cap. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company 74)cio (746v..14,4r- Ls.r..54.1.,-vs Date FA Name FA Address FA# ZWZ3eq7 PR # (,)5çi)4 6 q FA PE NIP Reviewed By /1/g7)/ Work Plan Date fErr--57 IR6--5--7 Authorization For Other to Sign Permit IRI‘ker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement afecd Agency Approval 1:241-2- COMMENTS/CONDITIONS: / 6,A. 5 k.„,,,,, 1 ,..,-tt„.....)ce,“4-e‘r rif ;-4,--e.c 4.0 et' A.15) (&.-C e 7 "G. 44 2) eileYes4c41 PK tat re F,..... erf„ 1, t,S, r9,p. re_d 6. ()See_ 1-6• SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# Permit 2905 13 $139 x 2_ 2:7 ff — 116‘6 5' i e 007 Z.1 1 8 Signed Print Name 1\1 etrA 1-2\v,Gr Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information ep7_ eiv zip/ ci-r- 3 DEPARTMENT USE ONLY e7/4/etic-4/Xce Date Issued: 7 7 A7/ 7 Siq 00767 /7 EI-10 29-01 10-26-2015 Site Mitigation Well Permit Application