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P191 yn'-�4-t S A N v 10 A Q U I N Environmental Health Department 4 •`�-r ----C O U N T Y---- 4 Greatness grows 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 Niotice k-equireci For Ali 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 21 I"y� ChWrC k Si, City/State/Zip v - f r Phone T Cross Street amkk { APN Property Owner' City/S Phone 20!3� �Lr,3 Address te2ip Ji o C-57 Contractor Ile _(At,�Dtr (1 V 1CL� - LL License# t b qq A q 5 Phone (p SQ 3Zrb Address !� i�12rn ✓ City/State/Zip FP+0'0 �,� ('� �(>31E)3 Consukant/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 WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporlWaler) ❑ HAMMER/DRIVEN 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: ElINJECTION(Air Soarae.ozw ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS [IHOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMER- DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED S ( OVER-BORE DIAMETER of,_jj_inches to depth ofS feet WELL IDs —p ❑PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED MALIGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP,• 'J❑3 feet below surface or feet below surface if>3 feet T�� COMMENTS: 8vQ-&q t/ I--y"l WJA+o xi' 9, 1-4It WA % TS) 1 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. Signed Title/Company r Print Name Date — —tr-1-OLI DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued: 3/29/2021 Grout Inspection By/Dates: n q i ,,rr11 Destruction Inspection By/Dates: V Facllit /Site Information FAName CITY LODI CENTRAL PLUM FAAddress 221 W. PINE, LODI FA# FA0012531 PR# PR0516247 FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 N C-57 ❑G57 Authodzation for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Pemet Access Agreement 0 Lead Agency Approval [$MFR COMMENTSICONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 WP TYPE I PE SC FEE INFO JAMT REMITTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 2902 313 $152x 2 1 304 010775 JW 1 3/16/2021 WP0041875 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD29-of 0"1-" SR0083463 Site Mitigation Well Permit Application