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Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates <br />Facillty/Site Information <br />DEPARTMENT USE ONLY <br />(JEFFREY VVONG) Date Issued: 3/29/2021 (5/3/2021, revised) JEFFREY VVONG <br />P.earAcl a <br />SANIOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />' <br /> G r en!,,cs grows here. <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 />,4A.4,44. ChAtApk • <br />Property Owner* riNtinf LK LA In 4 Lau_ rk, <br />Address <br />C-57 Contractor VIA- . y LtyytetS , LLC <br />Consultant/Sub-Contractor <br />City/State/Zip Legtid CFv Phone <br />APN pi+ ea5 2.4 cc, <br />Vt. Phone Peq_q-STLS <br />City/State/Zip pt.citrivt,nt, 01,51442 <br />License# k <br />„ <br />Bel) Phone &so ie <br />City/State/Zip cji4 alp 01-6 <br />License# Phone <br />Job Address <br />Cross Street <br />00 (tic!. <br />Address 2415 04 6r <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 WELUBORING <br />CI MONITORING <br />0 EXTRACTION (Vapor/Water) <br />LI SOIL VAPOR PROBE <br />111 SOIL BORING <br />I INJECTION (Air Soarae. Ozone) <br />OTHER <br />WELL/ SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 0 HAMMERER VEN <br /> 0 MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />El OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />LI BOLTED TRAFFIC BOX I=1 STOVE PIPE <br />El MULTIPLE CASINGS 111 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING 0 STEEL 0 PVC ID OTHER <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 0 PIPE <br />(Note: Maximum Freefall Depth Is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED 2- kitytw 1,44 OVER-BORE DIAMETER of inches to depth of214diSfeet (revised on <br />WELL IDs V viik - o PRESSURE GROUT To depth of feet below surface 5/3/2021 per <br />i D EXPLOSIVES GROUT SPECIFICATIONS tilifflpeo0 emtv,44 <br />TREMIE TYPE TO BE USED AUGERS HOSE 0 PIPE 0 MUSHROOM CAP 0 3 feet below surface or <br />From to feet below surface Brad Porter) feet below surface i1>3 feet <br />COMMENTS: VIA \Al c:, (Nut Jt, 23 I II tArA.s L._ tt A. 10, S ' OVERDRILL VM-5 SHALLOVV TO 25' <br />BSG & DEEP TO 45 BSG <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. <br />47,0466,*. i akIX1 Y Ck/ r li frf{ 1 <br />Date <br />- <br />Date 1110.1% as, 2. 1 itri-' 1 <br />Signed <br />Print Name clvAuchait <br />Title/Company <br />FA Name CITY LODI CENTRAL PLUMEFA Address 221 W. PINE, LODI FM/ FA0012531 PR# PR0516247 <br />FA PE 2960 WP Reviewed By JVV Work Plan Date 3/4/2021 <br />a C-57 0 C-57 Authorization tor Other to Sign Permit El Workers Comp CI Workers Comp Waiver 0 Encroachment Permit E4 Access Agreement r;ii Lead Agency Approval gi MFR <br />COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br />TOIAL 2 WELLS TO BE DESTROYED <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit 2902 313 $152x 4 304 <br />3n4 <br />010775 <br />cc <br />AA,/ <br />JW <br />3/16/2021 <br />5/3/2021 WP0041874 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EllO 29'01°8-(31-17confirmation #. 124755777 Site <br />5R0083463 <br />Mitigation Well Permit Application