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a SAN JOAQUIN COUNTY _�,.F• .o 2'" Cr ? ENVIRONMENTAL HEALTH DEPARTMENT LOP Q: • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Cr,9 t�—O Q ea�P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.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 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 Cnunty Environmental Health Department. Site Location 40 N.Main St. Cross Street E.Oak St.& E.Pine St. City/State Lodi/CA Zip 95240 APN city right-of-way Property Cit of Lodi 221 W.Pine Street L odi/CA 95240 209-333-6800 Owner y Address City Slate Zip Phone C-57 Contractor PeneCore Drilling Address 220 North East Street City/State Woodland/CA Lic 906899 phone 530-661-3600 Consultant/SubCntr E2C Remediation Address 5300 Woodmere Drive,Ste. 105 City/State BakersfieldlCA LIC 72685 Phone 661-831-6906 Billable Party City of Lodi Address 221 W.Pine Street CityfState Lodi/CA zip 9529-333-6800 GIS Coordinates:X Y RECEIVED CONSTRUCTION WORK TO BE PERFORMED: FED 2 8 2014 NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs _ _ a v�++ov u.+nRrT— ❑WELL IDs _-- -- _ ENVIReMON �— ❑OTHER IDs _- TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTIONrCtEtCATIQS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLP nLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNE30 -(PE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT fift REMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING [I PUSH POINT(GP/CPT) GROUT SEAL PIA44M:C]Yn (3 qc (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFIC^"CM_ , _❑OTHER: ❑OTHER: APPROX.BORING 007"__ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CAQ0(,1%0 rK using Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCE88 AGME-- \ TS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: METHOD:(CHECK ALL THAT APPLY) 17�OF WELL(S)TO BE DESTROYED DIAMETER OF or 10 INCHES TO DEPTH OF 3 FT WELL IDs: see attached page with the list of wells to be destroyed PAPE .TROUT TO DEPTH OFweII casing depttFT BELOW SURFACE GROUT SPECIFICATIONS neat-cement grout ❑EXP'"S' 7 FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE N PIPE 0 ARXw*%;.• z•.- CAP AT(>3 FT) YE _FT BELOW SURFACE COMMENTS see attached"Site Decommissioning Workplan"for destruction rn�fsd�i 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISS UAraCI FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will Lr u>Jrne r 4 -4� nce with San Joaquin County Ordinances, Rules and Regula" Lapp fl California laws. Signed ~ _ Title/C,mpary - C ! �c ti - Print Name 1 - i�'.l �C'_ Ljc W c-f Date DEPARTMENT USE U"vLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED Zbl3 APPLICATION ACCEPTED BY�L DATE ISSUED 1 AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE REQUEST PR# / fib . og Z 0 $125x f/ � 36 1 SR# O0�7 RO# ��3 �,�D -I�2'✓ � %�C__ /� 3500 _ 2900 D 5/ C-57 WC _ --WAIVER C-57 LETTER OF AUTHOR17-ATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-01 5/09/12 WELL PERMIT APP