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SANJOAQUIN <br />COUNTY-- <br />Environmental Health Department <br />Greatness grows her <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 Ali 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 a ,1 vq. 0 OL.k M'AU <br />Address (Al Pi <br />Cross Street ChLIArCk t4R-Lti. <br />Property Owner til 1%6, &-ree4 PINIA Ives LLC- <br />C-57 Contractor v1-1-thir .Ktv-u(cit LLe.. <br />2411. Ott g- Address <br />Consultant/Sub-Contractor <br />City/State/Zip CA- . <br /> <br />Phone <br /> <br />AP N <br />City/State/Zip c qs 20+0 <br />License# ( 044 Set Phone 650 <br />City/State/Zip P.4.51- &A e A4303 <br />License# Phone <br />o3,9,oct <br />PhoneRi___5101±Lnigh <br />Address <br /> <br />City/State/Zip <br /> <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELL/BORING <br />MONITORING <br />EXTRACTION (VaporWater) <br />SOIL VAPOR PROBE <br />10 SOIL BORING <br />0 INJECTION AI Soanie, Ozone) <br />OTHER <br />NUMBER INSTALLATION TYPE <br /> 10 HOLLOW STEM <br /> 0 HAMMER/DRIVEN <br /> El MUD ROTARY <br /> 0 PUSH POINT (GP/ CPT) <br /> 0 HAND AUGER <br />0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH <br />0 Yes 0 No Boring Dia: Casing Die: Casing Depth: <br />TREMIE TYPE TO BE USED: 0 AUGERS D HOSE 0 PIPE <br />GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS WELU SOIL BORING IDs <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />CONDUCTOR CASING <br />GROUT SEAL DEPTH <br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE <br />El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: D STEEL Li PVC 0 OTHER <br />DESTRUCTION WORK TO BE PERFORMED: <br />SV VW( <br />DESTRUCTION METHOD: (CFIECK ALL THAT APPLY! a_ai I i # WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of VO inches to depth of 21-146 feet <br />WELL IDs P- 0 PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED 'AUGERS 0 HOSE 0 0 MUSHROOM CAP D 3 feet below surface or feet below surfaced >3 feet <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 <br />Lke , <br />California laws. <br />e r, 1 ot khtv vsa Mei Signed c--4*----- ,C7 Title/Company ivini <br />i <br />Print Name IA rem 2 NA) 441 Date liw..c,K 2.,\ 2O2_( ) <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />JEFFREY VVONG <br /> <br />Date Issued: 3/29/2021 <br /> <br />i=g/ 9_6 I <br /> <br />Destruction Inspection By/Dates: <br />Facilltv/Site Information <br /> <br />FA Name CITY LODI CENTRAL PLUMEFA Address 221 W. PINE, LODI FA rt FA0012531 PR# PR0516247 <br />FA PE 2960 WP Reviewed By J1A/ Work Plan Date 3/4/2021 <br />0 C-57 00-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit [XAccess Agreement In Lead Agency Approval El 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 PE SC FEE INFO AMT REMITTED CHECK# RECIPD BY DATE WELL PERMIT# INVOICE# <br />Permit 2902 3 -3 $152x 4 E;OE 010775 JW 3/16/2021 WP0041876 <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />END 29-01 08-01-17 SR0083463 Site Mitigation Well Permit Application <br /> 0 EXPLOSIVES From <br />PIPE <br />COMMENTS: s v -04, ke, doh., Load 3.02.,:spi 4 upi (AA fogs , v (i*V1 A/N.)4 74 likiatil4041 1.01 (4,144 41 <br />to feet below surface