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1 SAN ) O A Q U I N Environmental Health nepartment SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andior install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address 1332 1C1345 . Sacramento Street City/State/Zip Lodi / CA 95240 _ Phone 415-424-3009 Cross Street Tamarack Drive APN 04530032 Property Owner' Vandertans Sons & Inc Phone Address 1320 S. Sacramento Street City/State/Zip Lodi / CA 95240 L' G C-57 Contractor 'VT6 711 1l0� ILL Licensex 6� S 4uPhoneL'7�� Address J 1 6 / at M�,1_1 n City/StatelZip —t / ! 7 ConsultanVSub-ContractorCi✓t) O s°G �-G License# PE/ - C -U 1 gPhLo/neg1[ y2y-�6Q 1 Address /7 , Fl foo a City/Stat./Zlp Lv5 /�c.0 / OZZ CONSTRUCTION WORK TO BE PERFORMED: 'Note. Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLtBORtNG NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORNG _� HOLLOW STEM BORING DEPTH 50_ ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIURNEN DIA OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ® SOIL VAPOR PROBE 10 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING. ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ) PUSH POINT (GPI CPT) CONDUCTOR CASING ❑ Yes ❑ No Bavq Dia Casklg Dia: Casing a" ❑ INJECTION Vie Scam ozone ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ ppTHER _ GROUT SEAL PUMPED? KI Yes No (Note: Malvnum Freelall Depth is 30 Ft WELLI SOIL BORING ID, fan reierenceS using GROUT SPECIFICATIONS Her conversation with Varinder beroi on 1/6/2022, permit/work plan is revised direct11Sh-fjrst_the.rL.H9A-iffefusal __ so all borings must be grouted from total depth to top by tremmie using neat cement and any well/probe/material in boring must be removed by overdrilling DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: )CHECK ALL APPLY) to the original boring depth. See email 1t WELLS TO BE DESTROYED ❑ OVER -BORE DIAMETER of inches todepth of leet correspondence 1/6/22 WELL IDs ❑ PRESSURE GROUT To depth of feel below surface JW GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface 0 >3 feet COMMENTS: Results must be submitted to EHD per SJC Well Standards 13.7.2 1 herehv rertifv that 1 am authorized to romnlate this annliration and that the work will be done in accordance with San,Jco)aq Courcy Ordinance Codes and Standards, and all other applicable Cal' ornia laws / 1 Signed LJ �/G _Title/Company AQ✓hC J 1 Y 1 Print Name -57 /,-A 17 !Jr e15S _Date _)Z Z Z Ll DEPARTMENT USE ONLY Application Accepted 6yJEFFREY WONG Date Issued: 1/6/2022 Grout Inspection By/Dates: _ Destruction inspection By/Dates: Facility/Site Information FA Name Lodi Southern Plume LSP FA Address 1 1345 S Sacramento FAQ FA0026941 PRx PR0547395 FA PE 2950 WP Reviewed By J W Work Plan Date 1 10/13/2021 KIC57 ❑ C-57 Authorir t Ior 09w to Sign Permd ❑ Workers Comp []Worker's Comp Waiver ❑ Enol. hrwt Perlmtt ❑ Access AgreerwI Q Lead Agency App(o+al E)MFR COMMENTS/CONDITIONS: Submit copy of report/results to EHD per SJC Well Standards 13.7.2 WP TYPE I PE I SG I FEE INFO AMT REMITTED1 CHECK # RECV D BY DATE WELL PERMIT# INVOICE# Permit 2903 1 313 $152 x 3 1 456 1 cc I JW 1 1/6/22 1 WP0042884 confirmation number: 136987033 SR0084701 1868 E Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 j www.sjgov.org/ehd EHD 29-0106-28-21 Site Mibgalwn Well Permit Application