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9-kam�1 �- � <br /> S A N M A Q U I N Environmental Health Department <br /> ----COUNTY <br /> Gr�utne�s yrr.=ws tret: . <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 /> Job Address , 91 t^tG City/State/Zip oar-, Phone <br /> Cross Street lt APN rC)43t)3 12� <br /> Property Owner' I Id( C, Phone 367 m4u <br /> Address (1i4 <br /> MP � City/State/Zip <br /> C-57 Contractor l 4 t&Dr tb T yteos L.L�' License# �OIL+114C � /� Phone �s0 <br /> Address �L ,� �, City/State/Zip ram} D ANO, �H !94-3.03 <br /> Consultant/Sub-Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporWater) ❑ HAMMER'DRNEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP!CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth. <br /> ❑ INJECTION(Air Sparse,ozcne) ❑ HAND AUGER. GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROY [2— ❑OVER-BORE DIAMETER of"inches to depth of a3- 65feet <br /> WELL]Ds ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS r ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED %AUGERS ❑HOSE [:1 PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: Jvp —O�J VVN L`411 LV�1 71� fit ( —41 1161l� 'AS t <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. /nf <br /> Signed Gr� Title/Company h)an(p-a ,11 Ofh6y S"l 1f III IG2t 1, <br /> Print Name PTIll Date 1 IlQ/�� 2,T i t <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: JEFFREY WONG Date Issued: 3/29/2021 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: Z®2..1 <br /> Facilit /Site Information <br /> FAName CITY LODI CENTRAL PLUM FAAddress 221 W. PINE, LODI FA# FA0012531 PR# PR0516247 <br /> FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 <br /> W C-57 ❑C 57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit JA.Access Agreement q Lead Agency Approval [)QdFR <br /> rM <br /> MENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br /> OTAL 2 WELLS TO BE DESTROYED <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2902 ` S152x 2 � �,,' j13;�'5 Jt�v 3/16/2021 WP0041873 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 2s-01 08-01-t7 SR0083463 Site Mitigation Well Permit Application <br />