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AN Q Environmental Health Department COUNTY Greotness grarvs 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 No Address ( 38 . 148297550081085 - 121 . 27002624634683) City/State/Zip Lodi , CA 95240 Phone N/A Cross Street Awani Drive + Mokelumne River Drive APN 041 -25- 038 Property Owner* City of Lodi Attn : Alice Bernardino Phone 209 -333-6706 Address 221 W. Pine Street City/State/Zip Lodi , CA 95240 C -57 Contractor Cascade License# 1069034 Phone 510-772 - 0841 Address 3459 Collins Ave City/State/Zip Richmond , CA 94806 Consultant/Sub -Contractor P & D Environmental , Inc. License# N/A Phone 510-658-6916 Address 55 Santa Clara Avenue , Suite 240 City/State/Zip Oakland , CA 94610 CONSTRUCTION WORK TO BE PERFORMED . * Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 18 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA . OF BOREHOLE 3 . 5 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS N/A TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER 0 SOIL BORING 2 ® PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes 0 No Boring Dia : Casing Dia: Casing Depth : ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs B1 and B2 GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED . DESTRUCTION METHOD : ( CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS . I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards , and all other applicable California laws . Signed � � 'V-\ , Title/Company Professional Geologist/P& D Environmental , Inc . Print Name Paul H . King Date 3/30/22 / DEPARTMENT USE ONLY Application Accepted By : Date Issued : � � Grout Inspection By/Dates : S' t w %' .r C- 1 . L Destruction Inspection By/Dates : Facilit /Site Information FA Name �� , — U�1gMi FA Address '.� � W FA# 0Q 2 �- PR# FA PEZ —1 5C� WP Reviewed By Work Plan Date ❑ C-57 9C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker' s Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency pproval ENR COMMENTS/CONDITIONS : MF C) r �L 1r "'> Z WP TYPE PE SC FEE INFO AMT REMITTED CHEC/ ® K�# RECV' D BY DATE WELL PERMOIT# INVOICE# Permit 2117 3 $ 152 x C � l31go { '+ 3 ZERO lo sR00B' sog2 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 1 www , sjgov . org /ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application