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S A N J OAQ U I N Environmental Health Department <br /> --COUNTY <br /> Greatness grows here. <br /> SITE WTIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> CALL (209) 468-3420 and ask for solid waste program to schedule inspection <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br /> Job Address 17720 E. Harney Lane City/State/Zip Lodi Phone 209-468-3066 <br /> Cross Street Clements Road APN 065-120-04 <br /> Property Owner* San Joaquin County - Public Works - Solid Waste Phone 209-468-3066 <br /> Address 1810 E. Hazelton Ave. City/State/Zip Stockton / CA 195205 <br /> C-57 <br /> Contractor Gregg Drilling License# 1044456 Phone 925-313-5800 <br /> Address 2726 Walnut Ave City/State/Zip Signal Hill, CA 90755 <br /> Consultant/Sub- <br /> Contractor License# Phone <br /> Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ® MONITORING 1 ❑ HOLLOW STEM BORING DEPTH 210 ft ❑ BOLTED TRAFFIC BOX KI STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE 10 IN M MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS SCH 80 TYPE OF CASING: ❑ STEEL ZI PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bodng Dia: 10 IN Casing Die: 2 IN Casing Depth: 209 FT <br /> ❑ INJECTION(Air saame.ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE <br /> ❑ OTHER [KI OTHER: SONIC GROUT SEAL PUMPED? ® Yes ❑ No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS NEATCEMENT <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: G-15 will be located to the south of the landfill. <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed - % • u - Title/Company San Joaquin County - Solid Waste <br /> Print Name MARK HOUGHTON' Date <br /> DEPARTMENT USE ONLY <br /> I <br /> Application Accepted By: BACKUS Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name North County Landfill FA Address 17720 E Harney Lane, Lodi FA# FA0004518 PR# PR0440058 <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval ❑ MFR <br /> COMMENTS/CONDITIONS: Payment by SST by Public Works-Solid Waste <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit 4471 1 $179 x 1 •0 ZCJ 2(p Dr <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 9 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EH 29-01 07-01-2025 Site Mitigation Well Permit Application <br /> `� 26 - �0 �� � 6 SrHc�o2DM <br />