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I SAN.DJOAQUIN Environmental Health Department —COUNTY \•ca<�i/E�oa 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 2 Phone Cross Street Multiple locations in City of Lodi ROW APN NA Property Owner' CITY OF LODI --� Phone 209-333-6800 Address 221 W Pine Street City/State/Zip LODI, CA 95240 pp q�3 d /?02y C-57 contractor GREGG DRILLING, LLC License# S (11 Ph no Address 950 Howe Road City/State/Zip Martinez, CA 94553 Consultant/Sub-Contractor CIVIL HYDRO TECH, LLC License# PE C69037 Phone 415424-3009 Address 581 MONTEGO TERRACE Clly/State/Zlp SUNNYVALE,CA 94089 CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Waler) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GPI CPT) CONDUCTORCASING ❑Yes ❑No Hodng Ole: Casing Din: Casing Depth: ❑ INJECTION t4soarae.oz«w1 ❑ HANDAUGER GROUT SEAL DEPTH THEME TYPETO BE USED: ❑AUGERS [I HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 FQ WELU SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALL THATAPPLYI Please see Well Construction Table #WELLS TO BE DESTROYED 17 ®OVER-BORE DIAMETER of_inches to depth of65 to 20gset r•tit) w/ y° WELL IDs SEE COMMENTS BELOW PRESSURE GROUJ To depth of feet below surface GROUT SPECIFICATIONS `❑-EXPLOSIVOT From to feelbelowsudace 1q"DD c, W/ II10 kf THEME TYPE TO BE USED ®AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAE 3feet helowsudace or feetbelnx surface if>3 feef n COMMENTS: G-08,Gy14A,�G-148,G-14QG-16C,G-180, G-18C, G-19A,MVy-f!� W-1 , MW-1 MW-15, MW-16, MW-17, MW-18, MW-26D, SA-5 Q�S Requesting that Well be pressure grouted as Ccessibilily Issues 7 ell constmctinn dela0e and Well.Location Fit u is attec ed with overhead power lines will prevent over bore -e k -.W YD Wf e -(-'c ,- M 13 1 hereby certify that I am authorize -t _complete this plicati and th8t the wdrk will be done In4cd ' �� ,�•i / San Joaquin County Or eJIn ace Codes and St�s,�Td4II other ap 11 to Callfoola laws. �.L. 4 Q`IKr•"gre l / I Tifle/Core an I4/zo �. O 0. Signed p y 'I'ro'ect M er GreggDril in LLC (,tl F Print Name Ryan Lea A - Date 4/1212024 (u ft• DEPARTMENT USE ONLY Application Accepted By: Date Issued: t at Grout Inspection By/Dales" //-- '/ Destruction Inspection By/Dales: '"' - Facili /Site Information 1, t _ FA Name i ��7 ,(.i lr� 1S-''<1C-I• Z- FAAddress 20 , w Q(a2 FA# (� PR# o 2_L FA PE C—I Q WP Reviewed By ork Plan Dale 2_3/Z0-z, ` 'PIG57 0C-57Au0wdufonforOtherto Sign Permil 10Workers Comp 7❑+ Workers Comp Waiv ❑Enwachment Permit Agmelmlent eW Agency Approval FR COM ENTS/C V NDITIONS: 1 Le i IX �N�t-'1� co-AC ire CLU VIT`Z� Ir¢✓i�A/ F 729) a- sp�atAw pe,m/ce A r-3 14 s C4 4 gO 'I h fkA- Cc pet A C s(nallcic, +a bt'xs er Ifi "Ve.M, eA 5/2j 2024- • WP TYPE PE I SC FEE INFO JAMT REMITTED CHECK# I RECV'D BY j DATE WELL PERMIT# INVOICE# Permit 2�OL 31.3 $162x 1p3 CC 5 ZI 2Uldr,?Q000,4 PP �r� :s t�spons; e mob t1; f�-- 1868 E. HazeltoLn Avenue I Stocktpn, lifornia 95205 1 T 209 466-3420 1 F 20 464-0138 1 www.sjcehd.com EHD 29-017-01-2023 1'eC 14 ,A;A WW , site MI a' nN'eA PennilApplication rI II .9 u,007,tj6