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P,prm� S A N j 0 A Q U I N Environmental Health Department v' ZL,, COUNTY SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Count/y�Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address {�(�wT i? © 1/� i 1`I Ipin City/State/Zip �„©(�� C A- Phone Am q3$ �QN Cross Street (>J n C � - _�—APN Property Owner" t_, Phone b '633 6IV/, Address tu I m F —City/State/Zip L4AL C, ` q.E?,_ o C-57 Contractor Ql L License# _—_l Phone �p SD 3-z'is SQ f-b Address g�� City/State/Zip epl+-&OQ`�3a3 Cons ultanUSub-Contractor License# Phone Address City/State/Zip CONSTRUCTION WORK TO BE PERFORMED: 'Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION vaporPNater) ❑ HAMMER!DR'VEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Sparse,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ff PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL'SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #WELLS TO BE DESTROYED OVER-BORE DIAMETER of r inches t0 depth of zgd feet WELL IDs - - - PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS KXPLOSIVES From - O to feet below surface(1I;5, (C,�a,175) TREMIE TYPE TO BE USED KAUGERS ❑HOSE VJPIPF _ ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet �COMMENTS: vg Walls lm —4'f W i �'� 2-4" Ins 1�'K' 1Ch1 UJ-n3 tm" (-2 Lud46231 4- 1-4�,WAEDltfsl %) 04 "VYl(Wosy I hereby certify that I am authorized to complete this application and that the work will be don in accordance with _ San Joaquin County Ordinance Codes and Standards,and all other applicable Cal#qrnia��l-aws. '' nn Signed �� 1_ Title/Company� / &6 '(A-Cl r &ry16, L u Print Name --prr TV1lN Date 'u , ?-oil DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG Date Issued: 3/29/2021 Grout Inspection By/Dates: ��77 Destruction Inspection By/Dates: OC l Facilit lsite Information FAName CITY LODI CENTRAL PLUM FAAddress 221 W. PINE, LODI FA# FA0012531 PRY PR0516247 FA PE 2960 WP Reviewed By J W Work Plan Date 3/4/2021 I4 C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ffAccess Agreement M Lead Agency Approval [X MFR coMMENTS/CONDITIONS:PROVIDE REPORT TO EHD PER SJC WELL STANDARDS 13.7.2 TOTAL 9 WELLS TO BE DESTORYED. NOTE: OBTAIN ENCROACHMENT/REVOCABLE PERMIT FROM CITY OF LODI AS REQUIRE WP TYPE PE SC I FEE INFO AMT REMITTED CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit 2902 31`t $152 x 5 1 760 010775 1 JW 3/16/2021 1 WP0041883 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 OMl-17 CHECK + CC CONFIRMATION NUMBER 123009418 Site Mitigation Well Permit Application SR0083463