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SAN JOAQUIN aEnvironmental Health Department err COUNTY 1� , F&xvZ j,, Greotne55 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 Altos , CA 95003 Cons uitant/Sub -contractor Partner Engineering and Science , Inc . License# NA Phone 559 . 907 . 7502 Address 1544 Eureka Road , Suite 180 City/State/Zip 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 ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMER/DRIVEN DIA , OF BOREHOLE Inches ❑ MULTIPLE CASINGS ❑ MULTI- LEVEL WELL CASING DIA SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESSNA TYPE OF CASING : ❑ STEEL ❑ PVC ❑ OTHER SOIL BORING 2 El PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes j 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 PIPE ❑ OTHER PC OTHER: Direct Push GROUT SEAL PUMPED? X.Yes ❑ No ( Notes Maximum Freefall Depth is 30 Ft) WELL/ SOIL BORING IDs B1 and B2 GROUT SPECIFICATIONS Grout via Counstv requirements . Neat Cement V 6 v � o f pro ,M , h o • Ire, � t It DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPCY) �t , - ,�— (►" ` n +( # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of PEP T' 4 �r 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 . Zhe y ertify that I 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. Signed Title/Company Project Geologist - Partner Engineering and Science Inc . Print Name Laure Hinch Date 6 . 15 . 22 DEPARTMENT USE ONLYvvl� �� Application Accepted By : Date Issued : Grout Inspection By/Dates : ,' c Z Destruction Inspection By/Dates : Facilit /Site Information n FA Name C � � � L f 04kkrMd S FA Address 13j> j � b�'fV � FA# 6C) 207 q PR# Ds3 � I FA PE y WP Reviewed By Work Plan Date �?'Z �R s� j ot ❑ C-57 -57 Authorization for Other to Sign Permit ElWorker's Comp ElWorker's Comp Waiver ❑ Encroachment Permit [1Access Agreement ❑ Lead Agency Approval [E] MFR Z COMMENTS/CONDITIONS : �- w t p M r/ 4"10C � ee i..e� WP TYPE PE SC I FEE INFO AMT REMITTED1 CHECK# I RECV' D BY I DATE WELL PERMIT# INVOICE# PermitT61 3 TW 152 x D cc10;&Z: WYOO 31+ ( AJ 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 46 & 34201 F 209 464 - 0138 1 www . sjcehd . com EHD 29-01 OS-01 -17 �. V1;f Vbr LG�` y �� ^ Site Mitigati�Well P�[r t P,pjlication