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Ram -L I-44r- I <br /> <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />t. I. 1:zfre. <br />SITE MITIGATION 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 />48 Hours Advance Notice Required For All Inspections <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 />4 S. elvhspr•KA— <br />Property Owner* obi) petka Et*LL.. A-C.g0C, <br />9(114tVat 414. <br />C-57 Contractor V ri-c(Apr •Ctrytees, C_ <br />Address '24 tt glib( &f.rt,t4- <br />, <br />Consultant/Sub-Contractor <br />City/State/zip C ph Phone <br /> APN SO ;„,(-) <br />Lt6t, Phone AtDet 36,1 61.313 <br />City/State/Zip Lok C ct 52,40 <br />License# (1)(44-1* Sqc Phone Co c t 32:6 PcCetb <br /> <br />Et-)64 Pfrio )CPr 6N-363 <br />Phone <br />Job Address <br />Cross Street <br />Address <br />City/State/Zip <br />License# <br /> <br />Address <br /> <br />City/State/Zip <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING NUMBER <br />El MONITORING El <br />EXTRACTION (Vapor/Water) El <br />01 SOIL VAPOR PROBE LI <br />El SOIL BORING 0 <br />El INJECTION (Air Spasm. Ozone) <br />OTHER El <br />WELL SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMEPJDRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH El BOLTED TRAFFIC BOX D STOVE PIPE <br />D MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL El PvC DI OTHER <br /> <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 1=1 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br /> <br />Boring Dia. Casing Dia: Casing Depth: <br /> <br />TREMIE TYPE TO BE USED: El AUGERS ci HOSE PIPE <br />(Note: Maximum Freefall Depth is 30 Fl) <br /> <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />; VVEL C,TD RE DESTROYED A—V imAjocv it. ;,. 1. lid 1115 r>tOVER-B OR E DIAMETER of Eifel inches to depth of 13f0415feet <br />WELL VrA opol 0.0,.. a v rA -pl. 4 Gv ",-(02,„ D PRESSURE GROUT To depth of feet below surface <br />GROUT SPEuiFICA4NS VatrillUb ttlfftt1I+ Gartt.i. 0 EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ZAUGERS El HOSE 0 PIPE 0 MUSHROOM CAP, 0 3 feet below surface or feet below surface if >3 feet <br />C OMMENTS: V 1.4 y.j—ot w44. (-v101400' 4 1-21( kill iott61 piplitich.,44, 1 yilutta-kiireT(-7.." 1A-tlit 4i, Les' <br />SY 6. -0 2. %IN 0Am/ft 4 --4“ WI 44, :A,' 4 (-Lit tvai 6 'is I ikm-A6441,4 (..2,1( LA k A V 4 (-V' kat( )4) ifs° <br />I hereby certify that I am authorized to complete this app cation and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable CalifornA laws. <br />Title/Company 6-6,41 t/f4-4/ r StgMf PC, 1.4.C. <br />Date <br />DEPARTMENT USE ONLY <br />Application Accepted By: JEFFREY WONG <br /> <br />Date Issued: 3/29/2021 <br /> <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />5P-1/,20 <br />FA Name CITY LODI CENTRAL PLUMEFA Address 221 W. PINE, LODI FA# FA0012531 PR# PR0516247 <br />FA PE 2960 WP Reviewed By J1.(\/ Work Plan Date 3/4/2021 <br />C-57 0 0-57 Authorization for Other to Sign Permit 0 Worker's Comp El Worker's Comp Waiver 0 Encroachment Permit ff Access Agreement 1:XLead Agency Approval N MFR <br />COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br />TOTAL 8 WELLS TO BE DESTROYED <br />WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 2902 313 $152 x 8 760 010775 JW 3/16/2021 WP0041872 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com <br />END 29-01 08-01-17 Sae Mitigation Well Perna Application <br />SR0083463 <br />Signed <br />Print Name 1..e y. r vt S)NtAuck,,,A,ti, Ilfikkack 20 20.“