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SA N.J OA Q U I N Environmental Health Department COUNTY Greatncsc prov;s here. 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 City/State/Zlp �� "C k Phone Cross Street 1h s}a APN 043 0'11� Property Owner" � 1 ` m LAAL tr Phone .601 1,�'2'� Address City/StatelZip /%A- C-57 Contractor Cts License# Phone (0 Jc) 3Zp Sq Address �7-(�Nmx6r 9k City/State/Zip 9fty p 443tL3. Consultant/Sub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMENDR VEN 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 IAIr Soarae.Ozoml ❑ 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) WELUSOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED OVER-BORE DIAMETER of inches to depth of2`I44S feet (revised on WELL IDs V 111A - 0 PRESSURE GROUT To depth of feet below surface 5/3/2021 per GROUT SPECIFICATIONS El EXPLOSIVES From to feet below surface Brad Porter) TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS:VMW-b2. 1ir�CtaAt. (ZK WtQ el$t * �-ZI (BMW fo4%1 OVERDRILL VM-5 SHALLOW 0 25' 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. Q. 1 ' Signed o.> Title/Compann,,y_ �Y1,Imde�a„ 1UY c1l r�K Lj-e- Print Name Date � OA DEPARTMENT USE ONLY JEFFREY WONG 3/29/2021 (5/3/2021, revised) Application Accepted By: (JEFFREY WONG) Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name CITY LODI CENTRAL PLUM FA Address 21 W. PINE, LODI FA# FA0012531 PR# PR0516247 FA PE 2960 WP Reviewed By JW Work Plan Date 3/4/2021 EX C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit M Access Agreement IX Lead Agency Approval P MFR COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 TOTAL 2 WELLS TO BE DESTROYED WP TYPE PE I SC I FEE INFO JAMT REMITTED CHECK#I RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2902 1 313 g152 x 4 304 1 01U/bj JW WP0041874 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com E1029.010s-ot-17confirmation 4: 124755777 SR0083463 Site Mitigation Well PermitApplieation