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� ©RIGINV. SAN JOAQUIN COUNTY �-r ENVIRONMENTAL HEALTH DEPARTMENT LOP <� SITE MITIGATION 1868 Hazelton Avenue,Stockton, CA 95205-6232 UNIT IV Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sigov.orci/ehd F� 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 Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Sita Location 6111 E Armstrong Road Cross Street Furry City/State Lodi,CA Zip 95240 APN 061-140-54 Property Kurt and Sandra Kautz Address 5490 Bear Creek Road Crty/State Lodi,CA Zip 95240 Phone (209)368-3113 C-57 Contractor Woodward Drilling Address PO Box 336 City/State Rio Visile,CA Lic 710079 Phone (707)3744300 Consuttant/Sub Cntr Fall Creeek Engr Address PO Box 7834 City/State Santa Cna-CA Lic 55605 Phone (831)426-1440 Billable Party Bear Creek Winery ,address 11900 N Furry Road City/State Lodi,CA Zip 95240 Phone (209)368-3113 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELLJBORING(CPT,GEOPROSE,HYOROPUNCH.HAND-AUGER,OTHER) ❑SOIL BORING Ifi ®WELL IDsMv ❑OTHER IDs TYPE✓L 8 OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _®MONITORING ®HOLLOW STEM DIA OF BOREHOLE 8 Inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 Inch _❑EXTRACTION:Vaporr Water ❑HAMMER/DRIVEN CASING THICKNESS SCh 40 TYPE OF CASING: ❑STEEL M PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 95 TREMIE 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(E a NrSoaroe.orore)❑HAND AUGER GROUT SPECIFICATIONS Neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 120 feet ❑BOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASING 14 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 WELLS)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr WELL IDS: ❑PRESSURE GROUT TO DEPTH OF 100 feet FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS Cj HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all n:n=, Signed TitWCompany Civil Engineer/Fall Creek Engineering Print Name Frederick A.Yukic Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED �4 APPLICATION ACCEPTED BY DATE IS'SU _-— pan GROUT INSPECTION BY FINAL INSPECTION BY nAIF�} 11�� DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC* PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR* 7 s 1 x w1)fSA- 9�3JSR# p 4a L D () 0;4 (r- 135 o PR# BOO NT C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DED EHD 29-01 5109112 WELL SEP - 3 2014 SAN JOAQGUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT