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SAN JOAQUIN Environmental Health Department COUNTY 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 complia with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 1200, 1201, 5 S. SACRAMENTO ST. City/state/ZIp LODI, CA 95240 Phone Cross Street PARK STREET,TAMARACK DR. APN 04529001, 04528008, 04529021, Property Owner' HOLZ RUBBER Phone Address 221 W Pine Street City/Statelzip LODI, CA 95240 fIv.QQ CJ ,3pl� C-57 Contractor GREGG DRILLING, LLC License# U 4i-t-1--t-Z N Phone Address 950 Howe Road City/state/Zip Martinez, CA 94553 ConsultantiSub-Contractor CIVIL HYDRO TECH, LLC License# PE C69037 Phone 415-424-3009 Address 581 MONTEGO TERRACE City/StatelZip SUNNYVALE, CA 94089 CONSTRUCTION WORK TO BE PERFORMED: *Note: OHs)te Borings/Wells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑HOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXiRACTION(VapoeWaler) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS MULTLLEVELWELLCASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPI) CONDUCTORCASING ❑Yes ❑No noting Ole: Casing Dia: Casing Depth: ❑ INJECTION(AFSoxae.Ozaw1 ❑ HANDAUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FQ 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 DESTROY ®OVER-BORE DIAMETER of 6-5 inches to depth of78 to 83 feet WELL IDS SA-1, SA-2, SA-4 D ckk El PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS an emen6 Bentonite [I EXPLOSIVES - From to feel below surface TREMIE TYPE TO BE USED ®AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feel below surface or feet below surface if>3 feet COMMENTS: All are 2-inch wells within the property boundaries. Well construction details are provided in attached Table. Location of wells shown in attached Figure. All wells are on parcels owned by Holz Rubber $" D gw3er ✓/ � 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with let— Joaquin County Ordinance Codes and Standards,and all other applicable California laws. 'O'� co W/ Signed let— Title/Company Gregg Drilling LLC Fof �tr �eQs Print Name Ryan Lea Date 4/12/2024 D RTMENT USE ONLY VU N1 f 2aZy Application Accepted By: t [Date Issued: r Grout Inspection By/Dates: Destruction Inspection By/Dates: -0, o-L_—A Facili /Site Information FAName LA', (TW Mt4r De NC pIZCJ41FAAddross I t lf) 54Cr- QtQ0_ FA# 00 i z ; PR# 0 j -Z4 FA PE Z WP Reviewed By Work Plan Dale /'Z3 'ao G57 ❑C57Authotizabon Wollner to Sign Permit ❑WorkeespComp muuw,eraar.,,nnw�, r rl Fncmahment Permit ❑Access Aglreeenuant Agency Almo'val FR CO E /COND , -(ti rg Zl LS-�r4�(. l ft�_ � �ck— , S kwdr� St�� 2Ykf(-- ° 5� 1a{�r �� : rlsfQll�f oM tf�`t un r ¢FPZ � . g evt �.`�jA 1a f'c WPTYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY AT WELL PERMIT# INVOICE 7 Permit Ni 3i3s,62X 3 ppI $ CC S,J =� 1 Zul oeo CC_ ( G I t i5 �'� LF- R P Zy"OO 3`( 1868 E. Hazelton Avenue I Stock o , alifornia 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 2941 7-M-2023 Site Mitigation well Permit Application