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S A NJ 0 A Q U IN Environmental Health Department C--1U (\I Y Grca n .., grows r,ere 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 521 North Cherokee Lane ' City/StatelZip Lodi, CA 95240 Phone (209) 601-6694 Cross Street Murray Street APN � /4("4e yv SI RED' � f' Property Owner" zU 1 'U"r,- ` -f IZ j[' phone (2Q91 663-6937 Address 3c123--htO,hodFFsvrr-Road r:ff,ac«�...,�•_. s CA S5224— rr C-57 Contractor L.L�k�N�Lr QeL7 G jCa(ID'-C fD tit ucensea /03 Y/gam_ Phone 77,gl-"Of Address /0-7rf f�11C� S O Its-S :-3j 9_CityfState/Zip kg5 e y,r�e L4 9r�7� Cons ultant/SUb-Contractor Stephen G. Muir Consulting GeologistLicense# CEG 1224 Phone (209) 369-9421 Address Po Box 152 City/State/Zip Woodbridge, CA 9-9256 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits ZYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f64JONITORING - f ❑ HOLLOW STEM eORING DEPTH P�80LTED TRAFFIC 8OX ❑STOVEPIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN CIA.OF BOREHOLE ._-f 7r ❑MULTIPE.E CASINGS❑MULTb11VEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:❑STEEL FLcvc❑OTHER ❑ SOIL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Cia:10 Caseltg Dia: 721 r Gam ng Degw: r)--rp•7 ❑ INJECTION(Kysum.promi ❑ HAND AUGER GROUT SEAL DEPTH -2-91' •yr TREMIETYPE TO BE USED.IAAUGERS ❑HOSE ❑PIPE t o�?'rC,yft.e ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes (Note M&KkW Freefaa Depth s 30 FI) 'y,•.IC �a��u NELU SOIL BORING IDs P 7 ATo.I f n -GROUT SPECIFICATIONS 9-s k mix or as directed by SJC£HD inspector. 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 1 ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: c`i l.�c^t �•, �l` /7 c-i ,Ltt7 17f� L t<ci 1 hereby certify that I am authorized to complete this application and that the work will be done In accordance with Sa Joaquin County Ordinance Codes and Standards,and all other applicable Californla laws. Signed 7 -L. t•1-` TitWCompany Stephen G. Muir Consulting Geologist Print Name Stephen , Muir Date " ZO Z 3 DEPARTMENT USE ONLY Application Accepted By:_ �,� I,' -�j� l.' r ) L•-t- _ Date Issued: Grout Inspection By/Dates: ' Destruction Inspection By/Dates: Facility/Site Information ++-- FA Name . Y C.y1Q1( FA Address iLI C /f^K i' FA# ��' -, ? ( PR# C' �? ti!'•� FA PE 2 1 WP Reviewed ByI Work Plan Date r ❑C-57 C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp U" r ❑Encmadwent Permit ❑AR*r Agreement ead Agency Approval IAFR COMMENTSl NDITIONS: �� S fL < 1�(i►trojt1 ' CL � re '��F -t� �S('-° ' �, ��i 19 J't, `I r• t'�.,,,—�, �=,:��r i Cc• i 1 7' e WP TYPE PE SC FE NFO AMT REMITTED CHECK# RECV'D BY DA WELL PERMfT# INVOICE# Permit x 2 � C 1 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 IF 209 464-0138 www.sjce d.com EHD 29-01 04-20-23 Site Mitigation Well Pwrtiit Application