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SAN JOAQUIN COUNTY � ENVIRONMENTAL HEALTH DEPARTMCNT N: 1868 Hazelton Avenue, Stockton, CA 95205-6232 I • •. = P • 9�ik'o'a�� (209) 468-3433 Web: www.segov.org/et. Telephone: 46 -3147 Fax: WELL & BORING PERMIT APPLICATION JAN 2 3 2015 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND_ TION AL NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMI SERV HEALTH is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliiaFnc� with San Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Roo, Site Location Chestnut Street Cross Street S. School Street City/State Lodi zip 95240 APN City Street Property Owner Cid of Lodi Address 221 W. Pine Street PO Box 3006 City/State Lodi zip 95240 Phone 209-333-6706 C-57 Contractor National EWP Address 1961 Meeker Ave City/State Richmond, CA Lic 953646 Phone 510-236-6282 Consultant/Sub Cntr Applied Water Resources Address 2363 Mariner Square Drive Suite 245 City/State Alameda, CA Lic 937701 Phone 510-671-2090 Billable Party Applied Water Resources Address 2363 Mariner Square Drive Suite 245 City/State Alameda. CA Zip 94501 Phone 510-671-2090 GIs Coordinates: x 38.129279 Y -121.27387 CONSTRUCTION WORK TO BE PERFORMED: ❑■ NEW WELL/BORING (CPT, GEOPRPBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs N I'IvJ 9 IN ❑■ WELL IDS NMW1 -A, B. C. D (NMWt-E is also a possibility) ❑ OTHER IDs TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q❑■ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 12-14 ❑ MULTIPLE CASINGS ❑9 MULTI-LEVEL WELL CASING DIA: 2 _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 2 TYPE OF CASING: ❑ STEEL 9 PVC ❑ OTHER _❑ SOIL VAPOR PROBE 9 MUD ROTARY DEPTH OF GROUT SEAL Various TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE 19 PIPE I ® SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: N Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION 0.e Air Sparge, Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS DWR Well Standards ❑ OTHER. ❑ OTHER: APPROX. BORING DEPTH 400-450 0 BOLTED TRAFFIC BOX OR ❑ STOVE PI' CONDUCTOR CASING 9 No ❑ Yes: Casing Dia: Casing Depth: Boring Dias_ COMMENT NOTE: (G� (V_,Gv (,C_ C U NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) # OF WELL(S) TO BE DESTROYED ❑ OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE❑MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, and all applicable California laws. Signed f Title/Company Geologist - AWR Corp Print Name ayram Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS LDD j jV0P_ 'y- `'lvUWlE ►9 2Fi'} WORK PLAN DATED J (A ►V -)zp/ 44 APPLICATION ACCEPTED BYr �f O V4•1cu v✓t DATE IS GROUT INSPECTION BY FINAL INSPECTION BY �7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE O $130, � SR# 7ty02 cRO I S?C) �� 33c� �ouvVJ I - Z3_ /5 # RO # U C-57 j/ WC ✓ WAIVER 42(j_ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT r ENCROACHMENT DOC 1r FHn 29-01 7/74/14 Wo 5 214 5 I t PFRMIT APP