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N- � ORIGINAL SAN aJOAQUIN COUNTY CRIGN ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION d'•. Y:� UNIT IV Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sigov.org/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 T'dle.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 11900 N Furry Road Cross Street Armstrong City/State Lodi,CA zip 95240 APN 061-160-26 Property 11900 N Fur Road Lodi,CA 95240 (209)368-3113 Owner Goldstone Land Co. LLC Address Furry City/State zip Phone C-67 Contractor Woodward Drilling Address PO Box 336 City/State Rovista.CA Lic 710079 phor, (707)374-4300 Consultant/Sub Cntr Fall Creeek Engr Address PO Box 7834 City/State sante Cn¢-CA Lic 55605 Phone (831)426-1440 Billable Party Bear Creek Winery Address 11900 N Furry Road City/Slate Lodi,CA ZIP 95240 phone (209)368-3113 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MW-5D.M - ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS DO MONITORING ®HOLLOW STEM OIA.OF BOREHOLE 8 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 2 Inch _❑EXTRACTION:Vapod Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL M PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 95 7REMIE TYPE TO BE USED:KI AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(I e kr Sparw_Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 120 feet ❑BOLTED TRAFFIC BOX OR ®STOVE PIPE CONDUCTOR CASING WJ No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) _§_#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: MW-1 MW-2 MW-3 MW-5 MW-6 ®PRESSURE GROUT TO DEPTH OF 100 feet FT BELOW SURFACE GROUT SPECIFICATIONS ea amen [I EXPLOSIVES FROM TO Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS M HOSE PIPE ®MUSHROOM CAP AT(>3 FT) 3 EeT -FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application ind that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable Californ a rr--II ^ I� Signed TilielCompany Civil Engineer >—u l� lit/ Q�C G►1 1�QQYl1� Print Name Frederick A.Y c Date !a-, 1 9 d EPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY (t K ats DATE 2 -/ DESTRUCTION INSPECTION BY DATE COM M ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# ;PE FEEINFO AMT REMITTED CHECK# REOWD BY DATE SERVICE RO# INVOICE REQUEST PR# s1s x SA. SR# o 0 0 91 �"D9aIq (9- I3 00 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMEW EHD 29-01 5109/12 ECEIVED SEP -3 2014 SAN JOAQUIEN NTY HEAL DEPA TMENT"