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; k lks Ocik &-4.4 City/State/Zip Loth: C <br />I ) <br />k.e s 04,4 - •A-Y APN Oti3 a t I <br />Property Owner* C. <br />Address , <br />C-57 Contractor rf'- .eYVI.Viekt LA.C. <br />Address 2.‘ bs? (Tu-65 SA, <br />Consultant/Sub-Contractor <br />Job Address <br />Cross Street <br />Lein e,b 3 TR. ffica- Phone euvics„5126q <br />City/State/Zip 1:1,14.6.1 C <br />License# o44 tqS Phone CID 37.-biAlo City/State/Zip F-14 (? q 4303 <br />License# Phone <br />Phone <br />Roth 41- <br />SANJOAQUIN ,e Environmental Health Department <br />COUNTY- <br />Greatness grows <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 fora 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 />Address City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: -Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />Li MONITORING <br />Li EXTRACTION (VaporiWater) <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Per Swim, Ozone1 <br />111 OTHER <br />WELL/ SOIL BORING IDs <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />Li HAND AUGER <br />CI OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH Li BOLTED TRAFFIC BOX Li STOVE PIPE <br />DIA OF BOREHOLE L1MULTIPLE CASINGS EI MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS <br />TYPE OF CASING: D STEEL D PVC 0 OTHER <br />CONDUCTOR CASING <br /> <br />Li Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIF TYPE TO BE USED: Li AUGERS 0 HOSE Li PIPE <br />GROUT SEAL PUMPED? D Yes 0 No (Note: Ma>dmum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION WORK TO BE PERFORMED: <br />It WELLS TO BE DESTROYED a -- Sve_ wiiik. <br />WELL IDs SV g• —0 <br />t GROUT SPECIFICATIONS S or i•144.1t) CA (MIA' Crarki- <br />TREMIE TYPE TO BE USED AUGERS 0 HOSE 111 PIPE <br />COMMENTS: sy a. 3 Vs‘a01144, t 6.r.t1A "6 220 gt- "-"+ 6kolt 4t) I <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />'.OVER-BORE DIAMETER of II inches to depth of 2 ;4C14Sfeet <br />['PRESSURE GROUT To depth of feet below surface <br />El EXPLOSIVES From to feet below surface <br />0 MUSHROOM CAP LI 3 feet below surface or feet below surface if >3 feet <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />••->i <br />Zan Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed ) L LC Title/Company MOOT 0011\ Dir AP(1..)Idg. <br />Print Name (41f r 11.N.Liuc),N.4,1 4 Date Ilianck <br /> <br />DEPARTMENT USE ONLY <br /> <br />3/29/2021 <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />JEFFREY WONG <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />L1/.2-4 <br /> <br />FA Name CITY LODI CENTRAL PLUMEFAmdress 221 W. PINE, LODI FM FA0012531 PR# PR0516247 <br />FA PE 2960 WP Reviewed By JW Work Plan Date 3/4/2021 <br />C-57 0 C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Workers Comp Waiver 0 Encroachment Permit EYAcces.s Agreement 0 Lead Agency Approval 7 MFR <br />COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br />TOTAL 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 313 $152x 7 304 010775 JW 3/16/2021 WP0041877 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 Site Mitigation Well Permit Application <br />SR0083463