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S A N J 0 A Q U I N Environmental Health Department F ---couN T Y-- - t�, Greatness grows r 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 a a` 3 oOk p J�4 City/State/Zip L'JA CA-) Phone Cross Street yka ft!+ 4y 6 (( APN I)�_ Q 3 ` Property Owner* C L(X1 ! 7 1 Q C(aL Phone � � Address 1J City/State2ip _�`.Qg-p�) ,c �- �,(�� C-57 Contractor &rv( Qi License# (44 tq S Phone (z s u 3LSe10 Address 2'S bQ MX6 Ir S�, City/State/Zip 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 WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaponWater) ❑ HAMMER/DRIVEN DIAL 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: ElINJECTION(Air Spam Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ElHOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mmdmum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ,OVER-BORE DIAMETER of I inches to depth of 2�Sfeet WELL IDs — ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS p fl ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS--ee❑� HOSE ❑PIPE ❑MUSHROOM CAP -'E]3 feet below surface or feet below surface f 53 feet COMMENTS: SV 3 V-'CA&+R1a. `_r„ l wv '* 2,41 6, 1,_,+tt � +Z) l 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. SignedC_�'� Title/Company P I Print Name 4rrt� VAWC�w•l Date �nnCk 2-VN 167-1 DEPARTMENT USE ONLY 3/29/2021 Application Accepted By: JEFFREY WONG Date Issued: Grout Inspection By/Dates: �7 Destruction Inspection By/Dates: Facllit /Site Information FAName CITY LODI CENTRAL PLUM FAAddress 221 W. PINE, LODI FA# FA0012531 PR# PRO516247 FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 Q C-57 ❑C-57 Authorizaflon for Other to Sign Permit ❑Worker's Comp ❑Worke(s Comp Waiver ❑Encroachment Permit EYAccess Agreement 0 Lead Agency Approval 7 MFR COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 TOTAL 2 WELLS TO BE DESTROYED WP TYPE PE Sc FEE INFO AMT REMITTED CHECKS RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 $152 x 2 304 010775 JW 3/16/2021 WP0041877 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 wwvv.sjcehd.com EHD 29-W 08-01-17 SR0083463 Site Mitigation Well Permit Application