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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION !� %P.. Telephone:(206)468-3147 Fax:(206)468-3433 Web:www.sislov.orglehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED App kation 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. Live Oak Road 95240 061-160-02 Site Location 11818 N. Furry Rd Cross Street _ - City/State Lodi.CA zip APN Property Kurt and Sandra Kautz 5490 Bear Creek Road Lodi,CA 95240 (209)368-3113 Owner Address City/Stale zip Phone C-57 Contractor Woodward Drilling Address PO Box 336 City/State Rio Vista,CA Lic 710079 Phone (707)374-4300 ConsultantfSub Cntr Fall Creeek Engr Address PO Box 7834 City/State Santa Cnz CA Lic 55605 Pie (831)426-1440 Billable Party Bear Creek Winery Address 11900 N Furry Road City/State Lodi,CA Zip 95240 Pie (209)368-3113 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: El NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ®WELL IDs MVV-7D ❑OTHER IDs TYPE b i OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _E)MONITORING ®HOLLOW STEM DIA OF BOREHOLE 8 inch ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2 Inch _❑EXTRACTION:Vapor/Water ❑HAMMERJORIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL 19 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:®Yea ❑No(MAXIMUM FREE FALL DEPTH IS 50 FT) _❑INJECTION li hrSoame Ozone)❑HAND AUGER GROUT SPECIFICATIONS Neat cement _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 120 feet ❑BOLTED TRAFFIC BOX OR M STOVE PIPE CONDUCTOR CASING R 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 ALt.THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS 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 repared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and ReguMons,and all app bl IH is 1 Signed Title/Company C �/ �k "Ar L/Y �t Print Name DUI. DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED COMIRT-ETV-D APPLICATION ACCEPTED BY DATE I tro—"—"�AKffA GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE C OMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECKS RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# SR# 0 3500 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOS p0ApY�M"V NT' EHD29-01 5/09/12 WELtr3LB Ci\/ED SEP - 3 2014 SAN JOA60IN COUNTY ENVINONMENTAL iE1LTH DEPARTMENT