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o,* S <br /> Environmental Health Department <br /> S�N _10AQUIN p <br /> A - <br /> -COUNTY---- <br /> Greatness 9rCws h r <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 Flours 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 /> Job Address I I` W, p a.`{ City/State/Zip L -C I: Phone <br /> Cross Street hw L+R.1114,f APN 04*;03109r <br /> Property Owner' r G Phone 210 al 0 j <br /> Address F ! City/State/Zip Lbek(, C 6 a 5 24o <br /> C-57 Contractor r -%ArU(&t LiLt License# v— <br /> d1s Phone �50 32� �gla <br /> Address � �t�i� r -, City/StateMp (-Asr� d 1>�,o&-qL43a3 <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 WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRNEN DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarve.Ozone/ ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Ma)dmum Freefall Depth is JO Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL IHAT APPLY <br /> #WELLS TO BE DESTROYED - \Aj ❑OVER-BORE DIAMETER of Winches to depth of��feet <br /> WELL IDS &F^ ❑PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or p feet belowt surface 1>3 feet <br /> COMMENTS: sVF, 'O6 M tLoA. III,—L4 it), tl1+11 W }o1{St <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 Californ11ia--lLaws- <br /> Signed e� Title/Company � �,�(rti/1(y �rVlu Lke <br /> Print Name Date 2Oz <br /> JEFFREY WONG DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: 3/29/2021 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: .�cJ <br /> Facillt /Site Information <br /> FAName CITY LODI CENTRAL PLUM FAAddress 221 W. PINE, LODI FA# FA0012531 PR# PR0516247 <br /> FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 <br /> ❑G57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Enacachment Permit QAccess Agreement n Lead Agency Approval ®MFR <br /> COMMENTS/CONDITIONS: PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 <br /> TOTAL 4 WELLS TO BE DESTROYED <br /> WP TYPE I PE SC I FEE INFO AMT REMITTED I CHECK#I RECV-D BY DATE WELL PERMIT# INVOICE# <br /> Permit 2902 313 $152x 4 1 g08 010775 JW 1 3/16/2021 WP0041876 <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 S R0083463 Site Mdigefion Well Permit Application <br />