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Environmental Health Department SAN.d0AQUIN <br />— COUNTY -- <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />El BOLTED TRAFFIC BOX CI STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL 0 PVC CI OTHER <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMERDR VEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING 0 Yes ID No <br />GROU- SEAL DEPTH <br />GROU- SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />TYPE OF WELLJBORING NUMBER <br />El MONITORING 0 <br />El EXTRACTION (VaporPAixer) El <br />I=1 SOIL VAPOR PROBE <br />0 SOIL BORING <br />El INJECTION (Air Spam.. Ozone) 0 <br />0 OTHER El <br />WELL: SOIL BORING IDs <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: El AUGERS 0 HOSE El PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br />DESTRUCTION WORK TO BE PERFORMED• <br />-t <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />I-24eV/OVER-BORE DIAMETER of4 -Hsi inches to depth of a%-'46 feet <br />PRESSURE GROUT To depth of feet below surface <br />JEFFREY WONG <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />/2'3/2 I <br />3/29/2021 <br />Date Issued: <br />14'1)4 <br />z <br />g.1416- <br />,S2i11"-, <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 />City/State/zip Lb C Phone <br />APN tt-SDB o <br />oAL Phone 261 °t3L3 <br />City/State/Zip Lodi., CA- 015,14-o <br />License# to441/mS Phone ‘56 3* get CO <br />City/State/Zip ep,34. c 14. 14303 <br />License# Phone <br />City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <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 Jaws. <br />Signed Title/Company bn Off) <br />Trvv _CKLLuoksji, Date <br />FA Name CITY LODI CENTRAL PLUMEFAAddress 221 W. PINE, LODI FA# FA0012531 PR# PR0516247 <br />FA PE 2960 WP Reviewed By JW Work Plan Date 3/4/2021 <br />Ej C-57 El C-57 Authorization for Other to Sign Permit El Workers Comp 0 Workers Comp Waiver El Encroachment Permit 6 Access Agreement 21 Lead Agency Approval CA MFR <br />COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL S I ANDARUS 13. (.2 <br />TOTAL 4 WELLS TO BE DESTROYED <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECVD BY DATE WELL PERMIT# INVOICE# <br />Permit :2 --"C12 313 $152x 4 608 010775 JVV 3/16/2021 WP0041878 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 <br />SR0083463 Site Mitigation Well Permit Application <br />Address <br />C-57 Contractor Pt-14m.y" V (Le) L LC. <br />Address ata DtpittAk r 111-. <br />Consultant/Sub-Contractor <br />Address <br />Job Address <br />Cross Street <br />Property Owner* bt, Fiktvia 1.44 I)-s 6c, <br />(14 QtNe_ <br />Npa.tr6A- Avc, _ <br />te 4ft* N6.- <br />ck6 &Arutoi.1 <br /># WELLS 10 HE DESTROYED <br />WELL IDs <br />Print Name t/ <br />GROUT SPECIFICATIONS EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED UGERS LI HOSE El PIPE 0 MUSHROOM CAP 0 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: Sv w.t1 ViNcLuAixo. 1.-4+1% 4.6,11 A""61 1,j/211 1.+S1 4%1 ()Vt. kjst,13, it!) 6s r <br />VIPS - " Ove- 10.1,o9.