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� • �`uuW c\ <br /> SAN._JOAQUIN Environmental Health Department <br /> c'dtl�oN`P� 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 /> 141S 5 d � J Job Address 1 Ray Rd City/State/zip Lodi,CA 95242 Phone <br /> Cross Street Woodbridge Rd APN 01116026 <br /> Property Owner` d t p —ghj Phone <br /> Address 19 d ,;Z CilylStatelZlp Lodi, CA95242 <br /> C-57 Contractor Gregg Drilling License# 1044456 Phone (925)313-5800 <br /> Address 950 Howe Rd City/State/Zip Martinez,CA 94553 <br /> ConsultanUSub-Contractor Jacobs Engineering License# Phone (505)280-9088 <br /> Address 2201 Broadway Street Suite 03W101 City/StatelZip Oakland, CA 94612 <br /> CONSTRUCTION WORK TO BE PERFORMED: *Note: Offs(te BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH TBD <39 ❑BOLTEDTRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING DIA <br /> ❑ SOILVAPORPRO13E ❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ® SOILBORING 7 IN PUSH POINT(GP/CPT) CONDUCTORCASING [I Yes ❑No Boring Dia: Casing Dla: Casing Depth: <br /> ❑ INJECTION(AYsoarm ozone/ ❑ HANDAUGER GROLITSEALDEPTH ❑ THEME TYPE TO BE USED: ❑AUGERS ❑HOSE []PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Portland cement mum Frcefall Depth is 30 Ft) <br /> WEW SOIL BORING as HP-35, HP-36, HP-37 GROUT SPECIFICATIONS <br /> HP-42, HP-43, HP-44 HP-45 <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 Todepthof feelbelowsudace <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES From_to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS [I HOSE [I PIPE ❑MUSHROOM CAP ❑3 feel 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 /> tL San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed 7— Title/Company Gregg Drilling, LLC <br /> Print Name Jake Wilson Date 6/12/2023 <br /> ARTMENT USE ONLY <br /> Application Accepted By: ( •' Date Issued: <br /> Grout Inspection By/Dates: , <br /> Destruction Inspection By/Dates: <br /> Facility/Site,Information <br /> FAName 5300 K),QoJbr;J5Q_< FAAddress S 1►�S #,r FA# 10 PR# 05 <br /> FA PE WP Reviewed By / Work Plan Date Z 0 Z. <br /> C-57 El G57Authoriza6on for Other to Sign Permit ❑ftkefs Comp ❑Workers Comp Waiver ❑Encroachment Permit Access Agreement Lead AgencyApproval R <br /> COM NTS/CONDIrTIIONS: [)� •1 A6t-CO // / <br /> (nt�t ckor TlaJ2Tl PV ri o 1CW l S ✓� ` Tli� r�1RM I" M ds <br /> WP TYPE I PE ISC I FEE INFO IMP REMIT'rED1 CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit I Zit IS $156X 3 1 t&g wP�Sv l�� g <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 S .l .co Q <br /> EHD 29-01 04-20-23 Site Mitigation Well Permit Application <br />