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SAAQI NJ( UN Environmental Health Department ! COUNTY Greomess grow: he-re. 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 andlor 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 94 41 `. CitylStatelZip Laii .t1�. Phone Cross Street III . S}ate APIN 3 o3 2.4 Property Owner* �111 IA m Ar Lwu.f'l+ Ilk m Phone U44 V101i Address 1' ( CitylStatelZip 05'1,jr[� C-57Contractor _ -E;, s,� Gt� LLC License# �r�+�y Phone Address C } CitylStatelZip 4 "s. R�C qt 3k ConsultantlSub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite BoringslVVells Require Access Agreements or Encroachment Permits TYPE OF WELL SORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITOMNG ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporfWater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLL ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: El STEEL ❑PVC © OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air suarge.Ozonel ❑ 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) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:rCHFCK ALL THAT APPLY) #WELLS TO BE DESTROYED — OVER-BORE DIAMETER of_9L inches to depth o1214dilS feet (revised on WELL IDs PRESSURE GROUT To depth of feet below surface 5/3/2021 per GROUT SPECIFICATIONSlox 11 "1 ❑EXPLOSIVES From to feet below surfacerad Porter) TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if> feet COMMENTS:vM W—02 Vcdm46, ZK WW 6 2V 4- FZf W4 ``o 4S 4 OVERDRILL VM-5 SHALLOW 025, BSG, & DEEP TO 45' BSG 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. .� W"daJL Cyr�� Signed Ga�1 Title/Company y r!) LLC Print Name ci� Date DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG (JEFFREY WONG) Date Issued- 3/29/2021 (5/3/2021, revised) Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FAName CITY LODI CENTRAL PLUM FAAddress 21 W. PINE, LODI FA# FA0012531 PR# PR0516247 FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 [XC-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit N Access Agreement IR Lead Agency Approval g MFR COMMENTSlCONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 TOTAL 2 WELLS TO BE DESTROYED . ...... ................................ WP TYPE PE Se FEE INFO AMT REMITTED CHECK# RECV'D BY DATE, WELL PERMIT# INVOICE# Permit 2902 313 $152x 4 304 010775 JW 37161202 1 WP0041874 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 [ www.sjoehd.com EHO Zs-o,°e-°'-"confirmation #: 124755777 SR0083463 Uitigation site I well Permit Application