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u <br /> SANcJOAQUIN a <br /> Environmental Health Department <br /> —COUNTY <br /> Greotness 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 19105 Ray Rd City/State/Zip Lodi,CA 95242 Phone <br /> Cross Street Woodbridge Rd APN 01116011 <br /> Property Owner* Paula J.Lind Trust/Todd Marley Phone <br /> Address 19105 Ray Rd City/State/Zip Lodi, CA 95242 <br /> C-57 Contractor Gregg Drilling License# 1044456 Phone (925)313-5800 <br /> Address 950 Howe Rd City/State/Zip Martinez,CA 94553 <br /> Consultantsub-Contractor Jacobs Engineering License# Phone (505)280-9088 <br /> Address 2201 Broadway Street, Suite 03W101 Clty/State/Zip Oakland, CA 94612 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsile Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLMORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH TBD <30' ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) D HAMMERADRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPEOF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> M SOILBORING $_® PUSH POINT(GP/CPT) GONDUCTORCASING ❑Yes ❑No Boring Die: Casing Dia: Casing Depth: <br /> El INJECTION(Ftspeae.ozarre) ❑ RANDAUGER GROUT SEAL DEPTH THEME TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefail Depth is 30 Ft) <br /> WEWSOILBORMGIDs HP-31, HP-32, HP-33, HP-34 GROUT SPECIFICATIONS Portland cement <br /> H 3P 8 HP-39,,HP-40,'_HP-41' <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 ❑PRESSUREGROUT To depth of feet below surface <br /> GROUT SPECIFICATIONS [I EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE [I MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel <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 /> `L San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br /> Signed jw- Title/Company Gregg Drilling, LLC <br /> Print Name Jake Wilson Date 6/12/2023 <br /> �}-�> DEPARTMENT USE ONLY / <br /> Application Accepted By: VV Date issued: /Z0as" <br /> Grout Inspection By/Dates: ,f_1 II <br /> Destruction Inspection By/Dales: Alo e�Pw 7q�l 9eg"`- 7—)1 -20y`3 <br /> Facilit /Site Information <br /> FAName 5 LAU 7 /k-j'&Y— FAAddmss ,!5- (^� FA# 00Q�-�� PR# 5aq- <br /> FA PE WP Reviewed By J V/ Work Plan Date 12 A3 0 /ZZ , <br /> G57 ❑C-57Aulhodzation fa Other to Sign Permit ❑Workers Gaup ❑Workers Compwaiwr ❑Encroachmenl Permit 0Aooess Agreement aJQ Lead Agency Approval MFR <br /> COM Mk EN 1' o7tfy Cn Z CO gas fildf-5 <br /> Air : HOW FP e --(iW—vt6l rLk r104 IKA 0 as 4A o P-,fl <br /> WP TYPE I PE I SC I F FO AMT REMITTED CHECK# RECV-D BY I jkTE I WELL PERMIT# INVOICE# <br /> Permit 40 3156 X % $ CG 000 <br /> C 00 S� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcelS om <br /> EHD 29-0f 04-20-23 Site Mitigator,Well Permit Application <br />