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SAN JOAQUIN Environmental Health Department <br /> COUNTY— <br /> Greatness gr4:vs hef'e. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours Advance Notice Required For All Inspections <br /> CALL (209) 953-7697 For 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 212 W. PINE STREET City/State/Zip LODI, CA 95240 Phone 415-424-3009 <br /> Cross Street PLEASANT AVENUE / APN 04303203 _ <br /> Property Owner* GREG DAVIS 1 �'�4L( � (`f�i% l�l L (� =Phone <br /> Address 212 W. PINE STREET City/State/Zip LODI, CA 95240 <br /> C-57 Contractor VTS DRILLING LLC License# 916085 Phone 415-378-0415 <br /> Address 31693 HAYMAN ST City/StatelZip HAYWARD, CA 94544 <br /> Consultant/Sub-Contractor CIVIL HYDRO TECH LLC License# PE C69037 Phone 415-424-3009 <br /> Address 649 DISTEL DRIVE City/State/Zip LOS ALTOS, CA 94022 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING STEM BORING DEPTH 40 El BOLTED TRAFFIC BOX El STOVE PIPE <br /> El EXTRACTION(Vapor/Water) ElHAMMER/DRIVEN DIA,OF BOREHOLE .25—t,c3❑ 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(GP/CPT) CONDUCTOR CASING [I Yes ❑ No Boring Dia: _Casing Dia; __ Casing Depth: <br /> I—] INJECTION(Arsoaroe.Ozone) ElHAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ElAUGERS ElHOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ®Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELD SOIL BORING IDs SV-1 and SV-2 GROUT SPECIFICATIONS <br /> _ Te, Pay ary - �r ��� - �a e �a d �I Q ,rer� R ram, <br /> DESTRUCTION WORK-T�-BEP r DESTRUCTION METHOD: (CHEC ALL THAT APPLY) �c7rT <br /> #WELLS TO BE DESTROYED 2 Fr�c)ki ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs_ )- I —�— ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS NQw� f'or'1lcti�� cew►t ❑ EXPLOSIVES From to feet below surface <br /> TREMI E TYPE TO BE USED ❑ AUGERS ❑ HOSE PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: �� <br /> I hereby cer#ify_thatI am auth&ized to complete this application and that the work will be done in accordance;witft <br /> San JoAquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed Q C- Title/Company <br /> Print Name er1 3V P-t s,3 Date l li5AS <br /> IANfiEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: 140/ 2-CI-2 <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: Al Yl {' +J�� L ) _ <br /> Facility/Site Information <br /> FA Name tV FA Address ; FA# D PR# <br /> FA PE , (� (2 <br /> WP Reviewed By L Work Plan Date 2d ' <br /> b,C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑ Encroachment Permit ❑Access Agreement '-dead Agency Approval -` MFR <br /> COMFIENTS/CONDITIONS: c <br /> r <br /> DWAQ-ice �or- �' Vk w <br /> � t % <br /> _ <br /> WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV-D BY DATE WELL PERMIT)# INVOICE# <br /> Permit Z"1 $1,5 x <br /> 77>P, Q <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 04-04-07 Site Mitigation Well Permit Application <br />