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i <br /> a <br /> ou" <br /> E °z�, SAN�J OAQU I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> SITE MITIGATION WELL & BORING PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 24 Hours 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 125 N Stockton St City/State/Zip Lodi,CA 95240 Phone <br /> Cross Street Locust St APN 043-084-130 <br /> Property Owner" City of Lodi Phone <br /> Address 221 W Pine Street City/State/Zip Lodi,CA 95240 <br /> C-57 Contractor Cascade Environmental License# 1058336 Phone 916 638 1169 <br /> Address 3000 Duluth Street City/State/zip West Sacramento CA 95605 <br /> Consultant/Sub- License# Phone <br /> Contractor Address City/State/Zip <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 15'bgs 0 BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE 2" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ® SOILVAPOR PROBE 20 ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER <br /> EI SOIL BORING FT-❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes VNo Boring Die: 2.25 Casing Dia: 1/4"TeflonCasing Depth: <br /> ❑ INJECTION(Air Soarge.Ozone) ❑ HAND Al1CF GROUT SEAL DEPTH ('S� TREMIE TYPE TO BE USED: ❑AUGERS CHOSE 1 41PIPE <br /> ❑ OTHER C OTHER:UU GROUT SEAL PUMPED? ❑Yes 121 No (Note:Maximum Freefall Depth is 30 Ft) 1 1 <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS Portland Cement <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of inches to depth 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 belm surface if>3 feet <br /> COMMENTS: �V r Skh(.,L S -,ra�l�� In� r[ vN OU bt e�G( 6D qc <br /> I hereby certify that I am authorized to tomplete 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 Title/Company Cascade Drilling <br /> Print NameRlck Alcartado Date6/13/25 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: :j 4-==="A1 Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facility/Site Information / <br /> FA Name �! FA Address (Z S �ti S T L �� FA# �j l ( PR# L` C� <br /> FA PE a SJ WP Reviewed By Work Plan Date <br /> 19:C-57 ❑C-57 Authorization for Other to Sign Permit Workers Comp ❑Workers Coh Waiver ❑Encroachment Permit access Agreement ❑Lead Agency Approval MFR <br /> COMMENTS/CONDITIONS: t ZU S V t ll S of l (3�r µ <br /> �S VZ- <br /> P �- <br /> A <br /> WP TYPE PE 2Sc2 FEE INFO AMT REMITTED CHECK# RECV'D BY DATE/ WELL�IPERMIT# Q INVOICE# <br /> Permit 7 t7 $172x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-2024 )LG7�<pD 2- -� Site Mitigation Well Permit Application <br />