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WEW SOIL BORING IDs EVV-7R <br />CONSTRUCTION SPECIFICATIONS <br />BORING DEPTH 120 ft S/BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA OF BOREHOLE 12" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CONDUCTOR CASING El Yes WINto Being Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH +1- 58" TREMIE TYPE TO BE USED: "AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED? El/Yes 0 No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS Npat rimmAnt/I1WR wp11 c tam-tar/lc <br />CASING THICKNESS 2" TYPE OF CASING: GATEEL 0 PVC El OTHER <br />DESTRUCTION WORK TO BE <br />If WELLS TO BE DESTROYEu <br />WELL <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE WED 0 AUGERS lJ HOSE 0 PIPE <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br />9 OVER-BORE DIAMETER of inches to depth of feet <br />PRESSURE GROUT To depth of feet below surface <br />EXPLOSIVESFrom to feet below surface <br />El MUSHROOM CAP El 3 feet below surface or feet below surface if >a 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 />§170...1 uln Ordinance Codes and Standards, and all other applicable California laws. <br />- <br />Print Name <br />Signed Title/Company 0 eloybc>"2,— 6"-e-cf- <br />Date <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />1r sst.;4:.. <br />TYPE OF WELL/BORING <br />0,MON1TORING <br />ig EXTRACTION hia <br />SOIL VAPOR PROB <br />SOIL BORING <br />INJECTION (Ali Sparta. Orono <br />OTHER <br />NUMBER INSTALLATION TYPE <br /> 0 HOLLOW STEM <br />1 0 HAMMER/DRIVEN <br /> 0 MUD ROTARY <br /> CI PUSH POINT (GP/CPT) <br /> 0 HAND AUGER <br /> tsi OTHER: Sonic <br />.• <br />1 <br />FOR <br />DEPARTM T USE ONLY <br />SAN JOAQUIN <br />)UNTY <br />Environmental Health Department <br />RECEINIED <br />SITE MITIGATION WELL & BORING PERMIT APPLICATICitiP 1 9 2017 <br />For Wells and Borings Used for Contaminant Investigations and Remediati_o_n_ <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENVIRoNMENTAL HEALTH <br />PERMIT/SERVICES <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 531 S. Church Street <br />Cross Street Tokay Street & Church Street area APN 04502031 <br />Property Owner* City of Lodi <br />Phone NA <br />Phone 209-333-6800 <br />City/State/Zip Lodi, CA, 95420 <br />Address 211 W. Pine Street <br /> <br />City/State/Zip Lodi CA 95421 <br />C-57 Contractor Gregg Drilling License# 485165 Phone 925-313-5800 <br />Address 950 Howe Road <br /> <br />City/State/Zip Martinez, CA 94553 <br />Consultant/Sub-Contractor Water Rock Construction Corporation License# 983523 Phone 510-671-2095 <br />Address 2363 Mariner Square Drive, Suite 243 city/state/zip Alameda, CA, 94501 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />FA Name '-"k"jt il'11^4 eivat, Iti <br />11C.4- 34441 /447,4k1,0 A VJLAA <br />FA Address 531 CAA."'"r"f• c'er FA# 00v4/2.6,5- PR" 0592_2-621 <br />FA PE XI k0 WP Reviewed By L ,)4 Work Plan Date '4 Ii 8, ft -7 <br />CI C-57 I2K-57 Authorization for Other to Sign Permit lil'Ittorkers Comp 0 Workers Comp Waiver erncroactiment Permit 0 Access Agreement IiKead Agency Approval Cie<FR <br />COMMENTS/CONDITIONS: WeA.A -A sy,AA .... NW. (>4-0.4 V.41) t0..ykV4t- skit- aP -.V .,r-e}A.:Ii4 P:e-S° <br />WP TYPE PE SC FEE INFO MAT REMITTED CHECK# RECV'D BY DATE WELL PERMIT* INVOICE# <br />Permit 9 Cli 0 t 31-5 $152x 1 v,--2. -31 /4,26 L. )t Lit , <br />i Nolo v-)evo3 iql <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 Wen Permit Application <br />ill S-14 t, IL; L-A li1J4111 sv-ocrivz-0 03 S2:5 SL