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SAN JUAWN <br />___....00UNTY-_- . <br />GrcaEnoss yro:V5 her.:. <br />ivironmental Health Department <br />SITE MITIGATION WELL & BORING PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />24 flours Advance Notice Required For All Inspections <br />CALL (209) 953-7697 For 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 6220 East State Route 12 (Victor Road) <br />Cross Street North Kennison Lane <br />City/StatelZip <br />Lodi, CA 95240 <br />APN 049-12Q-020 <br />Phone 209-369-2154 <br />Property Owner" Russell Trovinqer Phone 209-369-2154 <br />Address 6220 East State Route 12 (Victor Road) CitylState/Zip Lodi, CA 95240 <br />C-57 Contractor AdvancedGeo, Inc. License# 1063735 <br />Add837 Shaw Road Stockton <br />ress <br />City/State/Zip , CA 95215 <br />Phone 209-467-1006 <br />Consultani/Sub-Contractor same as C-57 Constrictor License# 1Q63735 Phone <br />Address <br />City/State/Zip <br />CONSTRUCTION WORK TO BE PERFORMED: •Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br />TYPE OF WELUBORINC NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 5 and 15 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />❑ EXTRACTION (VaporMater) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE 1.54 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA <br />SOIL VAPOR PROBE 5 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />III SOIL BORING 2 ❑ PUSH POINT (GP! CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: <br />❑ INJECTION (Air Sparge, ozone t (] HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED, ❑ AUGERS ❑ HOSE ❑ PIPE <br />❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes El No (Note: Maximum Freefall Depth Is 30 Ft)� (f A O <br />WELLlSOIL BORING IDs V1 through V5 and B1 and B2 GROUT SPECIFICATIONS Neal Cement (6 gallons per94lbs bag) W Co NN <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># WELLS TO BE DESTROYED ❑OVER -BORE DIAMETER of inches to deptfi of feet <br />WELL IDs ❑ PRESSURE GROUT To depth of feet below surface <br />GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface <br />TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet <br />COMMENTS: <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />Signed �v Title/Company Senior Geologist <br />Print Name Daniel Villanueva <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Destruction Inspection By/Dates: <br />FacilitvlSite Information <br />Date 11-16-2021 <br />FA Name <br />mamu aC <br />FA Address <br />G ZZU <br />FA# <br />1000 <br />PR# <br />FA PE <br />�� <br />WP Reviewed By <br />Work Plan bate <br />171C-57 ❑ C-57 Authorization for Other to Sign Permit <br />❑ Worker's Comp [I Worker's Comp Waiver ❑ Encroachment <br />Permit <br />❑ Access Agreement El Lead Agency Approval ❑ MFR <br />COMMENTS/CONDITIONS: �'µ <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D BY <br />DATE <br />WELL PERMIT#,I., <br />INVOICE# <br />Permit <br />1, <br />1$152 x <br />11111414 <br />N6o4Z+✓ <br />1868 E. Hazelton AvenLle � Stockton, California 95205 � T 209 468-3420 � F 209 464-00138 1 vvww.sjgov.org/ehd <br />EHD 29-01M2&211 r��, !a1 � eon, 01 a � Site Mitigation Well Permit Application <br />