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<br />SITE MITIGATION WELL & BORING PERMIT APPLICATION (P4,
<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 531 S. Church Street City/State/Zip Lodi, CA, 95420 Phone NA
<br />
<br />Cross Street Tokay Street & Church Street area APN 04502031
<br />Property Owner City of Lodi
<br />
<br />Phone 209-333-6800
<br />Address 211 W. Pine Street city/state/zip Lodi. CA. 95421
<br />C-57 Contractor Gregg Drilling License# 485165 Phone 925-313-5800
<br />Address 950 Howe Road City/State/Zip Martinez. CA. 94553
<br />Consultant/Sub-Contractor Water Rock Construction Corporation ucense# 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 BoringsNVells Require Access Agreements or Encroachment Permits
<br />TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />Cl MONITORING 0 HOLLOW STEM BORING DEPTH 125 0 BOLTED TRAFFIC BOX D STOVE PIPE
<br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE 7'. 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />0 SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS 6-3/4" TYPE OF CASING: 0 STEEL VPVC 0 OTHER
<br />KeSOIL BORING 0 PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes Efhlo Boring Dia: Casing Diai asing Depth:
<br />INJECTION **aim Ozavik 0 HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE PIPE
<br />OTHER t2r OTHER: Sonic GROUT SEAL PUMPED? 0 Yes 0 No (Note: Maximum Freefall Depth is 30 Ft)
<br />GROUT SPECIFICATIONS Neat cement/540 Bentonite
<br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY1
<br /># WELLS TO BE DESTROYED 0 OVER-BORE DIAMETER of inches to depth of feet
<br />WELL IDs 0 PRESSURE GROUT To depth of feet below surface
<br />GROUT SPECIFICATIONS 0 EXPLOSIVESFrom to feet below surface
<br />El MUSHROOM CAP D 3 feel below surface or feet below surface if >3 feet TREMIE TYPE TO BE USED J AUGERS 0 HOSE PIPE
<br />COMMENTS:
<br />I hereby certify that I am authorized to complete this application and that the work will be done In seeestanes with
<br />an 4 r___)p County Ordinance Codes and Standards, and all other apglesble Cal mla laws.
<br /> Title/CoMpanqietire77/0 0/V4.1O-C9's greifir 40//116',".p,
<br />Date
<br />WELU SOIL BORING IDs
<br />Signed
<br />Print Name
<br />Application Accepted Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />L74 /DEPARTMENT USE ONLY
<br />Date Issued: I
<br />FA Name '.1,'et,- I t•,-CA Clu---,
<br />taX., C-4.ii.a.tArv, .-N v(-41/4 FA Address 5 3 i S. CA,,, (i. A.,.. S- i FA# c„ c, 4..1 .z....cs-- PR# OiStit
<br />FA PE i Di:1 %67 WP Reviewed By L - yiy Work Plan Date (
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<br /> 1 .z.7 i i -3
<br />0 C-57 ILVC-57 Authorization for Other to Sign Permit 1:910;ker's Comp 0 Worker's Comp WaiverUE Encroachment Permit 0 Access Agreement MK:ad Agency Approval ei-AFR
<br />
<br />COMMENTS/CONDITIONS: c7,-c ,A.- Cenrc.lnexA"
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<br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# I NVOICE#
<br />Permit , i c, , ---,i; i -,., $152x i I, 1 c 2_ cl . 2-V)-16. L -)( II 13111 VI e IX; ; 1 C'Y
<br />1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 I www.sjcehd.com
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<br />EHD 29-01 08-01-17 Site Mitigation Well Permit Applicn
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