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Phone
<br />CitylState/Zip Martinez. CA 94553
<br />License# 983523
<br />City/State/Zip Alameda, CA, 94501
<br />TYPE OF WELL/BORING NUMBER
<br />MONITORING
<br />EXTRACTION (Vapor/Water)
<br />0 SOIL VAPOR PROBE
<br />SOIL BORING
<br />INJECTION (rtir Erten, or: rt:
<br />OTHER
<br />WELU SOIL BORING IDs
<br /> 0 HOLLOW STEM
<br /> 0 HAMMER/DRIVEN
<br /> 0 MUD ROTARY
<br />0 PUSH POINT (GP/ CPT)
<br /> 0 HAND AUGER
<br />OTHER:
<br />Property Owner City of Lodi
<br />Address 211 W. Pine Street
<br />C-57 Contractor Gregg Drilling
<br />Address 950 Howe Road
<br />Consultant/Sub-Contractor Water Rock Construction Corporation
<br />Address 2363 Mariner Square Drive, Suite 243
<br />city/state/zip Lodi. CA. 95421
<br />License# 485165 Phone 925-313-5800
<br />510-671-2095
<br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits
<br />BORING DEPTH
<br />CIA. OF BOREHOLE
<br />CASING THICKNESS
<br />CONDUCTOR CASING 0 Yes 0 No
<br />GROUT SEAL DEPTH
<br />GHOU r SEAL PUMPED', 0 Yt'..; 0 ro
<br />GROUT SPECIFICATIONS
<br />o BOLTED TRAFFIC 30X 0 STOVE PIPE
<br />0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER
<br />Boring Dia: Casing Dia: Casing Depth:
<br />TREMIE TYPE 10 BE USED: 0 AUGERS 0 HOSE 0 PIPE
<br />(Note V..rntlin rfoQw Dorm i:: 37 El)
<br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />GROUT SPECIFICATIONS Neat Cement/540 Bentonite
<br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE VPIPE 0 MUSHROOM CAP 03 feet below surface or feel below surface if >3 feet
<br />DESTRUCTION WORK TO BE PERFORMED:
<br /># WELLS TO BE DESTROYED 1
<br />WELL IDs EW-7
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY1
<br />(2'OVER-BORE DIAMETER of 12 inches to depth of 125 feet
<br />EI PRESSURE GROUT To depth of feel below surface
<br />El EXPLOSIVES From to feet below surface
<br />COMMENTS:
<br />Application Accepted By. Date Issued. V, +
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />/
<br />DEPARTMENT USE ONLY
<br />Phone 209-333-6800
<br />Date
<br />Title/Company 0/?e,re..? '7%0),24-727/.," 22,74 -^,
<br />441,7
<br />Signed
<br />Print Name
<br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with
<br />an Joaquin Ccitinty Ordinance Codes and Standards, and all other applicable California laws.
<br />(?/0///.2
<br />SAN JOANN
<br />(_) U N
<br />4,&)
<br />Oc>,
<br />3.17 Environmental Health Depattvent,"
<br /><<s 10,
<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 />43 ]-ic.ilivs 'c2vanc Noic3P.erlt..5ci or
<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 City/State/Zip Lodi, CA, 95420 Phone NA
<br />APN 04502031 Cross Street Tokay Street & Church Street area
<br />
<br />FA Name - ----,..
<br />-ii... i--)ciir44-10--, k.J-€44 FA Address VI, i 5 C. -4: (- 3 F ck, ...,..v2..v.i..,,,,-, PR# I ,
<br />FA PE )(1( i5- - -..-- '
<br />WP Reviewed By ! L -y, I
<br />Work Plan Date I ' • I - --i i 1 I 1 Z...1
<br />0 C-57 0C-57 Authorization for Oilier to Sign Permit 0 Worker's Comp 0 Worker's Corny Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval RIR
<br />COMMENTS/CONDITIONS: 1/4.:, , ,„ ,. - .\ k::_ ,„ „,,- -.-- , ._ ‘ .. .-, ' ' - sk , .-- v- - • 14 .
<br />t -44-- C ..,4,...Ail bit. 60 ,,,,i-r.,.v.e---
<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 />END 29-01 08-01.17 Ste Witigaiton Penrt ApO1:a!lon
<br />4;3 5-7.3 isLx litcp
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