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S I S A N 10 A Q U I N Environmental Health Department 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 212 W. PINE STREET City/State0p LODI,CA 95240 Phone Cross Street S PLEASANT AVENUE APN 04303203 Property Owner' GREG DAVIS(PINE STREET PARTNERS,LLC) Phone Address 212 W.PINE STREET City/StateJZip LODI,CA 95240 C-57 Contractor VTS DRILLING LLC License# 916085 Phone 415-378-0415 Address 31693 HAYMAN ST CitylStateMp HAYWARD,CA 94544 Cons ultanUSub-Contractor C IV L HYROTEC HI-LC License# PE C69037 Phone 415-424-3009 Address 581 MONTEGO TERRACE City/State/Zip SUNNYVALE,CA 94089 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite BoringslWells Require Access Agreements or Encroachment Permits TYPE Of WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 20 to 40 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ *CTRACTION(VapodWaeer) ❑ HAMMEPARIVEN Dtk OF BOREHOLE 2.25-INCH ❑MULTIPLE CASINGS❑MULTILEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THIDOESS TYPE OF CASING: ❑STEEL ❑PVC❑ OTHER ® SOIL BORING 1 T'+ -. ► _❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes❑No Bm%Tka Casing Ora: Casi g Depth: ❑ INJECTION(Ail$".Q.. ❑ HAND AUGER GROUT SEAL DEFni TREME TYPE TO BE USED: Cl AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER:--- GROUT SEAL PUMPED? ❑Yes ❑No (Note:Mwmm RwW De0 is 30 Fq _ WELL)SOL BORING IDs ---- _ GROUT SPECIF)CAT10NS r ✓ ' ` ('r) S(3 L tY- DESTRUCTION WORK TO BE PERF MED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED 1$ [I OVER-BORE DIAMETER of inches to depth of feet I�t'tI�WELL IDs - S-1 ate, ❑PRESSURE GROUT To depth of feet below surface re616AGROUrsPECIFlCATIoNS El EXPLOSIVES From to feet belvwsrrtace TREMIE TYPE TO BE USED AUGERS HOSE PIPE ❑MUSFROOM CAP ❑3 Teel below surteoe or feet below surface R>3 feet Tj COMMENTS: l� 11 46tsoil borings(20 to 40 ft deep)which will be grouted after collection of soil samples I hereby certify that I am authorized to complete this application and that the work will be done in accordance with s n Cra_unty Ordinance Codes and Standards,and all other applicable C liforma laws. (� igned TdleJCompany �� ^, m �/` % I�n II,Ac ��C Print Name C7)6nn U. etSS Date -? 'DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: r Ill Destruction Inspection By/Dates: SE?�� -f— 1 —z t S � ..r-Q Facili /Si a Information IL -t/ �LJ I" Atl FA Name ;"r.4, ._,t F t FA Address W— FA# C Pft# FA PE { h WP Reviewed N Worfc Plan Date G57 ❑G57 Aitav=w to Other b Sign Perm ❑WorWs Comp ❑Workers Comp Wanw ❑Enonaivneni ft t ❑Aeoecs Agreement Lead Agency Apprv4 [Q MFR ICOMMENTS/CONDITIONS:�, 1 �S��S �—J I_, WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'O BY DATE WELL PERMIT INVOICE# Permit 2 (�� x ' >< v r c- S/z z 4w 2-13It� 42 1 abvs� -E-1� j� C-,� I � � �.., ,-�,�,ous j;�1 �t .1� N S e.�,i,r cn� d�:s :rs - c{t M, r ��aw C wok cv✓2r+ecQ l.� fie_ Ic,� c ktcj� � t/,��;-dot rs LL ►4.{�,rbc:�+1 C �5 :ll ��, C��er fjYJrd TtcH , � 9.-/z0/20 Vne-xcr rvl r n 3 ti r-.