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NJ°NOUIN� SAN JOAQUIN a ---� Environmental Health Department COUNTY `PgOFoa � Greatness grows here . SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All 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 1301 E Lockeford Street City/State/Zip Lodi , CA 95240 Phone 559 . 647 . 7766 Cross Street E Lockeford Street/N Cluff Avenue APN 049- 34- 026 Property Owner* Ken Sommers Phone 559 . 647- 7766 Address 380 West Spruce Avenue City/State/Zip Clovis , CA 93611 C-57 Contractor Environmental Control Associates , Inc. ( ECA) License# 695970 Phone 916 . 417 . 6858 Address 3011 Twin Palms Drive City/State/Zip Aptos , CA 95003 Consultant/Sub-contractor Partner Engineering and Science , Inc. License# NA Phone 559 . 907 . 7502 Address 1544 Eureka Road , Suite 180 City/State/Zlp Roseville , CA 95661 CONSTRUCTION WORK TO BE PERFORMED : *Note : Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 40 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELLCASING DIA SOILVAPOR PROBE 4 ) MUD ROTARY CASING THICKNESSONN TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER �( SOIL BORING 2 El PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION (Air Sparge, Ozone) ❑ HAND AUGER GROUT SEAL DEPTH U N K TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE JAI PIPE ❑ OTHER OTHER: Direct Push GROUT SEAL PUMPED? NLYes ❑ No (Note- Maximum Freefall Dept( is 30 Ft) WELUSOIL BORING IDs 131 and B2 GROUT SPECIFICATIONS w Grout via County requirements , Neat Cement rit J 6 v o-P0 r pro We. M&. litdl 0 �1� r t I DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT AP ) # WELLS TO BE DESTROYED [:1 OVER-BORE DIAMETER of inches to depth of v feet ` r 4 W � s 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 : * Nested soil gas probes at 5 and 15 feet . I e y ertify that 1 am authorized to complete this application and that the work will be done in accordance with an Joaquin County Ordinance Codes and Standards, and all other applicable California laws. SignedYf� Title/Company Protect Geologist - Partner Engineering and Science Inc. Print Name Laure Hinch Date 6 . 15 . 22 �DEPAIRTMENT USE ONLY Application Accepted By: Date Issued : Grout Inspection By/Dates : Destruction Inspection By/Dates : Facilit /Site Information �je / FA Name Cw `- '�� tri-+'S FA Address r 3 D l b(�-�-�p l� FA# OC) 2/� PR# o5,3 v v l lZZ FA PE -` J� WP Reviewed By Work Plan Date ❑ C-57 Ef r,-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR Z COMMENTS/CONDITIONS : C � 1 _ iref p p y/ LST& , r 1 em ZoJ44� ) WP TYPE I PE SC FEE INFO AMT REMITTED CHECK# RECV' D BY DATE WELL PERMIT# INVOICE# Permit k 0, C7 152 x 2 O 0 cc I :T Ke': 1 Wft 3t 60 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www . sjcehd . com EHD29-01 08-01 -17COVI:fWKC� �}- � � � Site Mitjpati�Well P -ty lication