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SAN : 1 U AQ U I N Environmental Health Department COU NTY 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(38.14829755008108,-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 ❑x SOIL BORING 2 ® PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑x 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 ❑x No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs B 1 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 IN ❑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 '_\,1<"r\2 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: Destruction Inspection By/Dates: Facilit /Site Information FA Name FA Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd EHD 29-01 06-28-21 Site Mitigation Well Permit Application