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Job Address 230 North Church Street City/State/Zip Lodi, CA, 95240 Phone NONE <br />Cross Street Lockford APN 043-023-01 <br />Property Owner* Jim and Karen Weber Phone 209-482-3191 <br />ss Agreements or Encroachment Permits <br />Environmental Health Department <br />Greatness grows here. <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work escribed. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San aquin County Well Standards. <br />SANAOAQUIN <br />COUNTY <br />Address 2229 Manzanita Court City/State/Zip Lodi, CA, 95240 <br />C-57 Contractor All Well Abandonment License# 84859 Phone 916-363-9355 <br />Address 3369 Fitzgerald Road Suite B City/State/Zip Rancho Cordova, CA 95742 <br />License# Phone 209-467-1006 Consultant/SubContractor AGE <br />City/State/Zip Sto ton, CA, 95215 Address 837 Shaw Road <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells ReqUire <br />TYPE OF WELLJBORING NUMBER <br />MONITORING <br />EXTRACTION (Vapor/Water) 0 <br />SOIL VAPOR PROBE <br />SOIL BORING <br />INJECTION (Air Spam, Ozone) <br />OTHER El <br />WELL/ SOIL BORING IDs <br />CONSTRUCTION SPECTICATIONS r <br />BORING DEPTH . '-',„ •N 1^\ ,0 TED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE \ : ' VD MUL IPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS -, TYPE OF CASING: 1:1 STEEL 0 PVC El OTHER <br />CONDUCTOR CASING 0 Yes Crit‘k Boring Dia: Casing Din: Casing Depth: <br />Nsiwr ote: Maximum Freefall Depth is 30 Ft) Yes 0 No 'EX El <br />iREMIE TYPE TO BE USED: 0 AUGERS ID HOSE El PIPE <br />GROUT SL PUMPED? <br />GROUT SEAL DEPTH <br />GROISIVECIFICATIONS <br />INSTALLATION TYPE <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED Eight (8) <br />WELL IDs MW-1 to MW-4 and VW-1 to VW-4 <br />GROUT SPECIFICATIONS Portland <br />TREMIE TYPE TO BE USED E AUGERS l=1 HOSE El PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />El OVER-BORE DIAMETER of inches to depth of feet <br />EI PRESSURE GROUT To depth of 45 and 65 feet below surface <br />EXPLOSIVES From to feet below surface <br />El MUSHROOM CAP [E] 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <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 0 <br /> Li 74.'3 • <br />Title/Company Geologist / AGE <br />Print Name Name William Litt Date 08/01/2017 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />Date Issued: <br /> <br />FA Name FA Address FA# PR# <br />FA PE WP Reviewed By Work Plan Date <br />0 C-57 CI C-57 Authorization for Other to Sign Permit 0 Workers Comp 0 Workers Comp Waiver 0 Encroachment Permit 0 Access Agreement El Lead Agency Approval 0 MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application