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Rami1"�- I S A N')O A Q U I N Environmental Health Department - COU NTY--- 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 48 Hours Advance Notice Required For All Inspections 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. Job Address 4 & N"h ,,'- A-(r{'y City/State/Zip LPat--CA Phone Cross Street tw RtIt APN 0+A ?)221. Property Owner' Ft t6a 41,1, ksoc, _LeaL (� Phone),_0A 30 903 Address ( City/State/Zip 40 C-57 Contractor I r J Vice$ C License# l7 Phone (Os b 3-ZS S-grb Address 21$ baM6r S Irrj City/State/Zip (9140N} jC6 q1+ 3 ConsultanUSub-Contractor License# Phone Address C ity/State/Zi p CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/VJells Require Access Agreements or Encroachment Permits TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION Naper'A'ater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP!CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth. ❑ INJECTION(Air Sparse.Ozone) ❑ HAND AUGER. GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) W'ELU SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WEL'c TO RE DESTRO�Awb ✓ V d 1 (OVER-BORE DIAMETER of�inches to depth of`a�feet WELL Y rA rp(_ - ❑PRESSURE GROUT To depth of feet below surface GROUT SPEUIFICA�T NS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED tKAUGERS ❑HOSF ❑PIPE ❑MUSHROOM CAP I ❑3 feet below surface or feet below surface if>3 feet COMMENTS:�/1h W-Ol vv�tt t&., 1-aNW414V/u 4 1'Zn �O f�,y * I 1 yf 11+►W40I-$ 41-2'f W d �0 4 S' Sr6-oZ v�tWA,* 11, 4'f "A to IV 4 (-4r W4 It`IS t Vrl�'A" (?A Itj fo 94'4 (-Z'f b,U, 0�fsf I hereby certify that I am authorized to complete this app ication and that the work will be done in accordance with _ San Joaquin County Ordinance Codes and Standards,and all other applicable Californi laws`. (1� /� 9 CAS P y RIU�6r" 4,1, &rwjicP LAC_Signed Title/Company an Print Name ...w Dated r-k 1) 2ca— DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued: 3/29/2021 Grout Inspection By/Dates: Destruction Inspection By/Dates' Facilit /Site Information FAName CITY LODI CENTRAL PLUM FAAddress 221 W. PINE, LODI FA# FA0012531 PR# PR0516247 FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 IN C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker Comp ❑Worker's Comp Waiver ❑Encroachment Permit { PAccess Agreement [Lead Agency Approval [X MFR rM MENTS/CONDITIONS'. PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 OTAL 8 WELLS TO BE DESTROYED WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 $152 x 5 760 010775 JW 3/16/2021 WP0041872 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 SR0083463 Site Mitigation Well Perm t A.ppllcanon