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C)uJ iN,, C SAN JOAQUIN Environmental Health Department COUNTY- Greatness grows here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 Multiple locations in City of Lodi ROW City/State/Zip LODI, CA 95240 Phone Cross Street Multiple locations in City of Lodi ROW APN NA 5 1 r Property Owner* CITY OF LODI Phone 209-333-6800 Address 221 W Pine Street City/State/Zip LODI, CA 95240 1��-) f?c C-57 Contractor GREGG DRILLING, LLC + ' License# ��j Ph ne Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor CIVIL HYDRO TECH, LLC License# PE C69037 Phone 415-424-3009 Address 581 MONTEGO TERRACE City/State/Zip SUNNYVALE, CA 94089 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ 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: ❑ INJECTION(Air Sparge,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ 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 PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) Please see Well Construction Table #WELLS TO BE DESTROYED 17 ® OVER-BORE DIAMETER of inches to depth of65 to 20geet •� WELL IDs SEE IN COMMENTS BELOW RES PSURE GROUT-,' To depth of feet below surface �.,� .-fc: Z' �;�(�S• GROUT SPECIFICATIONS EXPLOS(`!E' From to feet below surface �U�'(� a%6L,• .,/ I I d 6 t TREMIE TYPE TO BE USED ®AUGERS ❑ HOSE ® PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 fe r ,41 COMMENTS: G-08, G-14A, G-14B, G-14C,G-16C, G-18B, G-18C, G-19A, M - W-11, MW-13; MW-15, MW-16, MW-17, MW-18, MW-26D, SA-5 �t`S Requesting that Well --1,,be pressure grouted as cessibility issues ell constructinn details and WeILLocation Figure is attached with overhead power lines will prevent over bore t ,pnn . I hereby certify that I am authorize - _complete this a plication and th the wdrk will be done in cc fT ,, San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed /10,Z_ Title/Company Project Manager, GreggDrilling, LLC Print Name Ryan Lea Date 4/12/2024 DEPARTMENT USE ONLY t Application Accepted By: , Date Issued: J F/ 2�4 Grout Inspection By/Dates/__R/_ Z Destruction Inspection By/Dates: Facilit /Site Information FA Name ; FA Address TL ' FA# PR# FA PE L ct CC) WP Reviewed By J Work Plan Date 3 7 3/ E-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiv ❑Encroachment Per; cess Agreement Aead Agency Approval YMFR COMM ENTS/CONDITIONS: '��cl� r. C -.11r/ i - ��i 1C� 0��'s"-{'►Z'yy� -�' �' ` � �:v r "v (_fi Z�?� a- 5' c{r� to►'r �'l Ul%y c skcl k� ti�,s �,r ,"� �- vimr aynl�-� 1 Z�� - CC i 5�l �t WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY . DATE WELL PERMIT# INVOICE# Permit � �� ' $162 x �3 C C S �� `l - 00 ble- . )> pb :ri,�c l re ► C;-�'�/ u2 �-�c>c G� �,�� t�rvl c- 1868 E. Ha�zelton Avenue Stockt�Q�, lifornia 95205 T 209 46 -3420 F 20 464-0138 www.s�cehd.com EHD 29 01 7 01 2 23 ;e VV Site Miti a on Well Permit Application