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Application Accepted By: JEFFREY WONG <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: 3/29/2021 <br />1-17 /202,1 <br />Pleync\ <br />SANJOAQUIN <br />--COUNTY <br />Greatness gf:ol.vs here. <br />Environmental Health Department <br />Loct CA I Cross Street CVAC girA,A,Li- <br />Property Owner* l'b e4 / No tstr ( C111400, I My kirry s 11 Phone /i9Ci 'Sf-t 1(13 <br />Address 44-fiell 010,4) ) (eirtAre3 ) 1S,,,ti 0/3 City/Ste/Zip 1-15e,ic <br />C-57 Contractor rOfitir Za 12 V't Ce % LL. License# t b 44 S 45 Phone % 6)50 31 fa Zti 9) <br />Address -t fit' Lk rlit44V -'- City/State/Zip RIC44- WO (4-8-b let5r C14-3P3 <br />Consultant/Sub-Contractor License# Phone <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 />1:1 MONITORING <br />El EXTRACTION (VaporlWater) <br />SOIL VAPOR PROBE <br />El SOIL BORING <br />INJECTION (Air Same, Ozone) <br />171 OTHER <br />WELU SOIL BORING IDs <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br /> 1=I HAMMER/DRIVEN <br /> El MUD ROTARY <br /> P PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING [3 Yes 0 No <br />GROUT SEAL DEPTH <br />GROUT SEAL PUMPED? 0 Yes 0 No <br />GROUT SPECIFICATIONS <br />f:=I BOLTED TRAFFIC BOX El STOVE PIPE <br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: 0 STEEL D PVC D OTHER <br /> <br />Boring Dia: Casing Dia: Casing Depth: <br />TREMIE TYPE TO BE USED: El AUGERS El HOSE El PIPE <br />(Note: Maximum Freefall Depth is 30 Ft) <br /> <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 Aii 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 />Job Address S S15-4-1‘14N C VMAXC k r. City/State/Zip <br />APN 01;11 03 gal <br />Phone <br />DESTRUCTION WORK TO BE PERFORMED: <br />ti-InauN eirtk <br />UGERS p HOSE 1:1 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />la OVER-BORE DIAMETER of II inches to depth ofa M feet <br />El PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVES From to feet below surface <br />ID MUSHROOM CAP El 3 feet below surface or feet below surface if >3 feet <br /># WELLS TO BE DESTROYED <br />WELL IDs S'y G. —o <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED <br />COMMENTS: 8v G- tine-LAI& tAidA .1-0 ;.1 1-4 4 tAittl $o (+S I <br /> <br />I hereby certify that lam authorized to complete this application and that the work will be done in accordance with <br /> <br />g, San Joaquin County Ordinance Codes and Standards, and all other applicable California laws <br />Signed <br />. <br /> Title/Company <br />Print Name <br />JO)? Ockittir .Rirvieles )LIC <br /> <br />111 g KW VA Date 2O2.1 <br />DEPARTMENT USE ONLY <br />FA Name CITY LODI CENTRAL PLUMEFA Address 221 W. PINE, LODI FM/ FA0012531 PR# PR0516247 <br />FA PE 7)0 WP Reviewed By JVV Work Plan Date 3/4/2021 <br />ti C-57 DC-57 Authorization for Other to Sign Pertrtit 0 Workers Comp 0 Worker's Comp Waiver 0 Encroachment Permit n Access Agreement n Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit 2902 313 $152x 2 304 010775 JVV 3/16/2021 VVP0041875 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EI-ID 29-01 08-01-17 SR0083463 Site Mitigation Well Permit Application