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. paOrAi P.. SANJOAQUIN COUNTY Environmental Health Department ul r 11\14 44'16 C r; c s r 5 1; C 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 VVell Standards. (EAs 1)-vt ,ck Chusck &14//t" Address 24.1 tt II) City/State/Zip C-57 Contractor P14-6kr- ,c4 t) eel Address (2 terNt—Dir- Consultant/Sub-Contractor Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLJBORING NUMBER ID MONITORING 0 EXTRACTION (VaporiWater) SOIL VAPOR PROBE LI SOIL BORING 1:1 INJECTION (Air Sparqe, Ozone) 0 OTHER LI WELL' SOIL BORING IDs INSTALLATION TYPE HOLLOW STEM HAMMER'DR VEN MUD ROTARY PUSH POINT (GP/ CPT) HAND AUGER OTHER: CONSTRUCTION SPECIFICATIONS BORING DEPTH DIA. OF BOREHOLE CASING THICKNESS 0 BOLTED TRAFFIC BOX El STOVE PIPE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA TYPE OF CASING: [71 STEEL D PVC 0 OTHER CONDUCTOR CASING 0 Yes 10 No GROUT SEAL DEPTH GROUT SEAL PUMPED? 0 Yes D No GROUT SPECIFICATIONS Boring Dix: Casing Die. Casing Depth: TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE (Note: Maximum Free/all Depth is 30 Ft) Job Address Cross Street Property Owner* City/State/Zip APN LedL, f4 s-g9-0 Licensed' I (+1+ (6q5 Phone 3va. Sgi-b City/State/Zip -64-7p o pjRi GH3 Q3 License# Phone e)& p Phone pal q53 6-7o,4 Phone bet -1% DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) tr WELLS TO BE DESTROYED 1-1-- OVER-BORE DIAMETER 01400 inches to depth of WID145 feet WELL IN cvg-61i inwTS kApti, pi/J-66 PRESSURE GROUT To depth of feet below surface TREMIE TYPE TO BE USED AUGERS El HOSE PIPE GROUT SPECIFICATIONS V 1p r,..) e-oricr- KXPLOSIVES MUSHROOM CAP El 3 feet below surface or From 2C) to att) 14—feet below surface (( (2+51 1b5, 4, 1;5) feet below surface if >3 feet CCIMMENTS: SVg• WILL UYNriji, As 4- 7,- 4" on co -03 wcAa.( -Z./LA.1146x; 4.. DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information JEFFREY WONG Date Issued: 3/29/2021 FA Name CITY LODI CENTRAL PLUMEFA Address 221 W. PINE, LODI FA# FA0012531 13R# PR0516247 FA PE 2960 WP Reviewed By JW Work Plan Date 3/4/2021 C-57 D C-57 Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver D Encroachment Permit I2Access Agreement 0 Lead Agency Approval a MFR COMMENTS/CONDMONS: pROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 TOTAL 9 WELLS TO BE DESTORYED. NOTE: OBTAIN ENCROACHMENT/REVOCABLE PERMIT FROM CITY OF LODI AS REQUIRED WP TYPE PE SC FEE INFO AMT REMITTED CHECK# REM/0 BY DATE WELL PERMIT# INVOICE# Permit 2902 313 $152x 5 760 010775 JW 3/16/2021 WP0041883 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 CHECK + CC CONFIRMATION NUMBER 123009418 Site Mitigation Wen Penn t Application SR0083463 tWUV& 6W-04 - (maul.* 1-6 11 4)}4 -Poiget", w---c) 5 vive114, 1-Vtaii 40156', Cuuaboidtik 1-6 k I hereby certify that lam authorized to complete this application and that the work will be donefin accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable Cal- rnia laws. Signed Title/Company \N./I-Z.64A d -C11 r r I L Print Name -1-.2r r ...v."41.A.ii- Date YntlACL 2.A U1 ELI