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S AN 10 A Q U I N Environmental Health Department SITE MITIGATION "G;" t)RING PERMIT mrr"MoATI%jN NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Cross Street 1332 �345�. Sacramento Street Tamarack Drive Property Owner* Vandertans Sons &Inc 1320 S. Sacramento Street C-57 Cantchactor Address 3 1 k ConsultantlSub-ContractorC i Address ft CitylStatelZtp Lodi 1 CA 95240 APN 04530032 City/State/Zip Lodi / CA 95240 Phone 415-424-3009 Phone License# Cj Phone 7�s"3�0 =��1� CitylState/Zip 8"Lm t —7 L% � r q License# PE4 �--� I Phone qYJ 441Zk � l Cltyistate/Zip L&.5 9 OZ2, kf CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite BoringsANells Require Access Agreements or Encroachment Permits TYPE OF WEWBORtNt; NUMBER INSTALLAjiON TYPE CONSTRUCTION $PECIFICATIONti ❑ iiONITOR1liG � HOLLOW STEM BORING DEPTH 50 ❑BOLTED TRAFFIC BOK ❑STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ itA►N.1DWRiVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTMEVEL MILL CASING DIA ® SOIL VAPOR PROBE 10 ❑ WD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC I❑ OTHER ❑ SOIL BORING PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Ba* Dia: Casarg Dia: Ca_scing Depth: ❑ INJECTION (ti kyoa Ozone) ❑ HANO AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE I I OTHER ❑ pTHEFL - GROUT SEAL PUWEDT X]Yes ❑ No (Node: Mmim� m Freefali Depth is 30 Fq WEWSOIL80RINGIDs t7rk—�talT relerenCeS USing GROUT SPECIFICATIONS Per conversation with Varinder Oberoi on 1/6/2022, permit/work plan is revised riirp f push hrSt then HRA if refusal so all borings must be grouted from total depth to top by tremmie using neat cement and any well/probe/material in boring must be removed by overdrilling DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION M614OD: (CHECK ALL THAT APPLY) to the original boring depth. See email # WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER of Inches to depth of fest VlELL IDs correspondence 1/6/22 ❑ PRESSURE GROUT To depth of feet below surface JW GROUT SPECIFICATIONS ❑EXPLOSIVES from to feet tt�owsurface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE. [I -PIPE- ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface 9 >3 feet COMMENTS: Results must be submitt ed to EHD per SJC Well Standards 13.7.2 1 hereby certify that t am authorized to complete this appflcation and that the work will be done to accordance with San J�o}a-q Cougty Ordinance Code$ and Standards, and all o�therlappllcabte Cal' ornia laws J Signed— - - -- Lam- -- - - - - TRWCompany- 3�1C- - LPWj tr _ .. - J r ! 1 Print Name 1 �� 5� Date 19 2 Z DEPARTMENT USE ONLY Application Accepted By: Grout Inspection By/Dates: Oeslruction Inspection BylD Facillty/Site Information JEFFREY WONG Date issued: 1/6/2022 FA Name confirmation num�er:�36987 33 SR0084701 1868 E. Haze ton venue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 { www.sjgov.orglettd EHD 29-01 Od-2&21 Site Mitigation VVen Permit Lodi Southern Plume LSP FA Address 1345 S Sacramento FA# FA0026941 PR# R0547395 FA PE 2950 wP Reviewed By J W Work Pian Date 10!13/2021 EIC -57 ❑ C57 Audio kzthn to Other to Sign Permit ❑ WaWs Comp ❑ W«Bees Camp Wa&er ❑ ErxroacNMt Perm t ❑ Acce<..s Agreement q Lead Agency Approval ®IJ.FR COMMENTS/CONDITIONS: Submit copy of report/results to EHD per SJC Well Standards 13.7.2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2903 313 s152 x 3 456__'] cc JW 1/6/22 WP0042884 AppMcaUrn