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SAN JOAQUIN COUNTY RIG I NAf <br /> 2` ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> .•I, :< 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE TIGATION <br /> •., - P Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd / <br /> q�IFOR��� <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JqN <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV/ 21 2OJQ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made Inc�h San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. /�/y/ Tk <br /> Site Location 712 South Sacramento Street Cross Street West Spruce Street City Lodi Zip 95240 APN 045-321 �lC�o <br /> �rl r <br /> Property 94583 <br /> Owner PG&E Address 3401 Crow Canyon Road City San Ramon Zip Phone 925-383-9517 <br /> )04XContractor PIVOX Address 7595 Irvine Center Drive,Suite 152 City Irvine Lic Phone 949-727-1400 <br /> ConsultanVSub Cntr Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine Lic 885321 Phone 949-297-4444 <br /> Billable Party Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine Zip 92618 Phone 949-297-4444 <br /> GIS Coordinates:X 3,01 11'F4 Y -12f . 1.724 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑ SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS ______TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i.e.Ar Searae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: _ __APPROX.BORING DEPTH___ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDS:OBS-1 through OBS-6,SVE-1,SG-2,SG-7 through SG-9.SG-12 through SG-14 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS All soil vapor wells will be removed during remedial excavation,and the areas backfilled with clean soil or slurry, <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all a tic ble 2attfomta Laws- <br /> Signed �� '—�' Title/Company� /04e, *j I Terra Pacific Group _ <br /> Print Name Rick McCartney / Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESSI� 717— S, 59-14R4oi<ore SA', _ 'k ob <br /> WORK PLAN DATED_ OCrP�'�C2 2U 12- <br /> APPLICATION ACCEPTED BY DATE ISS <br /> GROUT INSPECTION BY _ FINAL INSPECTION BY r) <br /> DESTRUCTION INSPECTION BY _ DATE—MeffilliMPL ~��•�� �S /Y <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> p REQUEST PR# <br /> z l $125. o ��1� dO(AWTL 1—z 1-I SR# 90 <br /> RO# <br /> 3500 <br /> 7— PR# <br /> 2900 <br /> C-57 LZ__ WC — __ WAIVER_ _ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ___ENCROACHMENT DOC <br />