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S A N J O A CJ 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 18.S. Pleasant Avenue City/State/Zip Lodi/CA/95240 Phone Cross Street Oak Street APN Alleyway between S.Pleasant Ave and S Church St.1 S.Pleasant Avenue Property Owner' City Of Lodi t •'L'{cj_(v�i V t�" Phone 209-333-6800 Address 1331 S. Ham Lane City/State/zip Lodi,CA/95242 C-57 Contractor VTS Drilling,LLC License# 916085 Phone 415-378-0415 Address 31693 Hayman St. City/State/zip Hayward/CA/94544 Consultant/Sub-Contractor Civil Hydro Tech, LLC License# PE-C69037 Phone 415-424-3009 Address 581 Montego Terraces City/State/zip Sunnyvale/CA/94089 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 40 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapo,[Wateq ❑ HAMMERIDRIVEN DIN OF BOREHOLE 2.25 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE -6 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC❑OTHER ® SOIL BORING 2 ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes❑No Boring Dia Casing DIa: Ceslrg Depth. ❑ INJECTION(Ar6oeraa.e:— Cl HAND AUGER GROUT SEAL DEPIH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE ❑ OTHER Cl OTHER: GROUT SEAL PUMPED? ❑Yes❑No (Note:Maximum Freefali Depth is 30 FI) WELU SOIL BORING IDs SP-1 and SP-2 GROUT SPECIFICATIONS L Temporary soil vapor probes to be installed in borings _ DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLYI #WELLS TO BE DESTROYED ®OVER-BORE DIAMETER of inches to depth of feet WELL Os ❑PRESSURE GROUT To depth of feel below surface GROUT SPECIFICATIONS ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ElAUGERS ElHOSE ®PIPE ❑MUSHROOM CAP ❑3 feel below surface or feel below surface if>3 feel COMMENTS: Temporary Soil Vapor probes to be sampled after 48 hours and destroyed by drillers to total depth by over drilling and tremie grouting using cement 4 SLR^5 11 hereby certify that I am authorized to complete this application and that the work will be done in accordance with DD San Joap�. �Crounty Ordinance Codes and Standards,and all other applicable California laws. O Signed�i an 0;�-t/u'aaTitlelComPanY Sole Member VTS Drilling,LLC � Print Name Glenn D. Reiss Date �4_ Application Accepted By: DEPARTMENT USE ONLY � t' Dale Issued: Grout Inspection By/Dates: LAI I()12� q 1 t 2r Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Add ess ( ht/ L v� FAK PRq V� [ . FA PE WP Reviewed By Work Plan Date I Z Z j^ . -57 ❑C-57 Authatralion for Other to Sign Permit 2,norkees Comp ❑Worker's Comp Waiver ❑Enaoachmen(Permil ❑Access Agreement [,Lead Agency A)provel gMFR ('nkA'm1--— NDITIONS: WP TYPE PE I SC FEE INFO AMT REmrrTEDj CHECK#IRECV'D f3Y DATE WELL PERMIT# INVOICE# Permit '1( t;-S '��. S172x , - ) 4'1• 25 W P250058 1868 E. Hazelton Avenue I Stockton, California 95205. 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com E H D 29-01 08-01-2024 �[t`1 13 f}v j_� I I I r t i v it,t)> Site Mitigation Well Permit Application 1.