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4 ` SAN JOAQUIN Environmental Health Department COUNTY SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 County Development Title, Chapter 9 1 a 15,3, and the San Joaquin County Well Standards. Job Address 212 W. PINE STREET City/State/Zip LODI, C 9y 240 Phone Cross Street PLEASANT AVENUE APN 04303203 Property Owner* _ GRE GDAV I S (ITNE ST REET PA RFNERS, LLC) Phone — Address 212 W Pine Street City/StatelZip �LODI, CA 95240�— C-57 Contractor VTS DRILLING LLC License# 916085 _ Phone 415-378-0415 Address _ 31693 H AYM A 1ST CitylState/Zip HAYWARD, CA 94544 ConsultantlSub-Contractor CIVIL HYDRO TECH, LLC License# PE C69 037 Phone 415-424-3009 Address 581 MONTEGO TERRAC E City/State/Zip SU NNWALE, CA 94089 CONSTRUCTION WORK TO BE PERFORMED: *Note; Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH _ 45 ❑BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(Vapor/Water) — ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 2.25 inch ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA _ ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _ ❑ SOIL BORING _❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No B oring Di Casing Dia: —— Casing Depth: ❑ INJECTION (Air Sparge Ozone) _ ❑ HAND AUGER GROUT SEAL DEPTH � MIE TYPE TO BE USED:]AUGERS ❑HOSE ❑ PIPE ❑ OTHER — _T❑ OTHER: GROUT SEAL PUMPED? )V/Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS I V T m a ot• roe c I ; ll ou'( `fo f e,0', ��Pary "J`otal d t� c/1 �o mM c1�1 5a me ,A DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION M THOD: (CHECK ALL HAT APPLY} #WELLS TO BE DESTROYED 2 E� 5 4%1 1lAr- ® OVER-BORE DIAMETER of inches to depth of feet WELL IDs SV-3 and SV-4 c rdho- ® PRESSURE GROUT To depth of---feet below surface GROUT SPECIFICATIONS Neat Portland Cement _❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED AUGERS (:] HOSE ® PIPE m 1 );I'e�, Dxti ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if>3 feet COMMENTS: Temporary Soil Vapor Probes to be sampled after 48 hours and destroyed by drillers to total depth by tremie grouting using Portland Cement pe SCQ- C %5 L rc I hereby certify that I am authorized to complete this application and that the work will be done in accordance with / fa Joaquin County Ordinance Codes and Standards, and all other applicable Californi laws. Signed �/hM !�dC Title/Company eM t!- (��J� O l ihfl U. 6 T_ Print NarTw : G I e,n r) D, �e,\SJ` Date OZ DEPARTMENT USE ONLY ` Application Accepted By: Date Issued: �c� 1 � 2 Q 2(— Grout Inspection By/Dates: -- Destruction Inspection By/Dates: FA Name LQ CP SA Ajj�a C,V T A Address Z` Z W _ FA# FA PE 2 b C7 WP Reviewed By Work Plan Date C 57 ❑ C 57 Authorization for Other to Sign Permit El Worker's Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ead Agency Approval gm-FIR COM ENTSICONDITIONS: S � co - r1C qr ,v l -K 4 ro WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY /DATE WELL PERMIT# INVOICE# Permit 2 D $162 x 2. z � FZ400o Zg CC- 11iforni7.535 AYI4t00 ? $S 1868 E. Hazelton Avenue I Stockton, a 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 7-01-2023 Site Mitigation Well Permit Application