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Signed V.)Mi()(4
<br />Print Name William Li
<br />SANJOAQUIN
<br />
<br />Environmental Health Department
<br />COUNTY
<br />
<br />(1,338 g 9f1V
<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 described.
<br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards.
<br />Job Address 230 North Church Street
<br />Cross Street Lockford
<br />City/State/Zip Lodi, CA, 95240 Phone NONE
<br />APN 043-023-01
<br />Property Owner* Jim and Karen Weber Phone 209-482-3191
<br />Address 2229 Manzanita Court City/State/Zip Lodi, CA, 95240
<br />C-57 Contractor All Well Abandonment License# 848359 Phone 916-363-9355
<br />Address 3369 Fitzgerald Road Suite B
<br />
<br />City/State/Zip Rancho Cordova, CA 95742
<br />Consultant/SubContractor AGE License# Phone 209-467-1006
<br />Address 837 Shaw Road City/State/Zip Stockton, CA, 95215
<br />
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />DIA. OF BOREHOLE
<br />CASING THICKNESS
<br />CONDUCTOR CASING
<br />GROUT SEAL DEPTH
<br />GROUT SEAL PUMPED?
<br />GROUT SPECIFICATIONS
<br />TYPE OF WELL/BORING
<br />o MONITORING
<br />EXTRACTION (Vapor/Water)
<br />EJ SOIL VAPOR PROBE
<br />SOIL BORING
<br />INJECTION (Air Sparge, Ozonel
<br />OTHER
<br />WELL/ SOIL BORING IDs
<br />NUMBER
<br /> 0 HOLLOW STEM
<br /> El HAMMER/DRIVEN
<br /> 0 MUD ROTARY
<br /> ID PUSH POINT (GP/CPT)
<br /> 1:1 HAND AUGER
<br />0 OTHER:
<br />0 BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER
<br />0 Yes 0 No Boring Dia: Casing Dia: Casing Depth:
<br />IRENE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft)
<br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />BORING DEPTH
<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 El AUGERS 0 HOSE 1:1 PIPE
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY)
<br />EfOVER-BORE DIAMETER of 8 inches to depth of 45 and 65 feet
<br />El PRESSURE GROUT To depth of feet below surface
<br />D EXPLOSIVES From to feet below surface
<br />El MUSHROOM CAP El 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 />Title/Company Geologist / AGE
<br />Date 08/01/2017
<br />DEPARTMENT USE ONLY
<br />Application Accepted By: 1-V\.
<br />Grout Inspection By/Dates:
<br />Via
<br />Destruction Inspection By/Dates: L -( 8'110/11 foi-1 1 „w--•ti 01-3 L -X IjJ, 14 401-11 mai—a Av./ -
<br />Facility/Site Information 11 NAV'
<br />FA Name
<br />....-
<br />1 cv.iv,r,(1/2.- V r oet FA Address 2,0 0 "tkAN Ckevnort.AA *44 FA# 0 0 0 1 k-tic' PR# 050 ‘53L
<br />FA PE r.)--clii 0 WP Reviewed By L -) Work Plan Date I Z fi- ( ,
<br />0 C-57 la6-57 Authorization for Other to Sign Permit Q#Korkel's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 ead Agency Approval alFR
<br />COMMENTS/CONDITIONS: ‘--e., Vs-AL c.9JA. tx.,.. -R.A.L.elL ....7 ‘4K-‘,..... ,,,,,u_p..k---- OA”. c....."A- i, _.....,.._ ...,4) A-1-4L,
<br />6.41-0 ,,..". v-e *Vt. t,,,,,,c \".4;1/4k, -0,,,,,w-,5 +,‘ .A.,-(...,--ce- . '%setifti-Q-(k. •---,,,dtt-Y- c, - (crk-..t}
<br />0,44 61„,s ... ,.A•
<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE#
<br />Permit )A L, L. i „. $152x ',:::- 1 1(00 .2 -.5 2- 1---X '5"1.7,41 ii i I") e OCA .1 0 LCS-
<br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com
<br />END 29-01 08-01-17 Site Mitigation Well Permit Application
<br />Date Issued:
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