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SAN JOAQUIN COUNTY DRIGINAl- <br /> f2. " ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> eP% UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si4ov.org/ehd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 5300 W Woodbridge Rd Cross Street Ray Road City/State Lodi,CA Zip 95242 APN 011-160-25 <br /> Property San Ramon,CA <br /> Owner Pacific Gas&Electric Company Address 3401 Crow Canyon Rd City/State Zip 94583 Phone <br /> C-57 Contractor Penecore Drilling Address 220 North East Street City/State Woodland,CALic 906899 Phone 530-661-3600 <br /> Consultant/Sub Cntr Parsons Corporation Address 2121 N California Blvd,Suite 500 City/State Walnut Creek, Phone 925-941-3700 <br /> Billable Party Consultant(see above) Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ©WELL IDs MW-12,MW-13,AS-1,AS-2,AS-4,OS-1 through OS-8(2"PVC);SVE-1,SVE-2,SVE-3,SVE-5,SVE-6,SVE-8,SVE-10,SVE-I 1 (4"PVC) <br /> ❑OTHER IDs SV-5,SV-6,SV-7,SV-8(soil vapor monitoring point;3/4"PVC) <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _2_El l MONITORING ®HOLLOW STEM DIA.OF BOREHOLE 3"to 12"❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 8 ®EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS Sch 40 TYPE OF CASING: ❑STEEL El PVC ❑ OTHER <br /> 4 ®SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 6 It bgs TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ®PIPE <br /> _❑SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> I 1 El INJECTION(Le Air SparOe.Ozone)M HAND AUGER GROUT SPECIFICATIONS Tremie grout with Portland Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 to 32 ft bgs ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Please see attached Work Plan Figures 3,7,9,13,15 for details on Well Construction and Well Locations <br /> NOTE: OFFSITE WELLS 8r 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: ❑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 <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have p5oled this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and ail is a California laws. <br /> Signed Title/Company Z'>MV nu <br /> Print Name t\) E-,I Date i)jLsl 1 Y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 3cz' 7 �'������r,< <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY 11 Y64Ku.n DAT AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BYI r�3_.., " "-e DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICERO# INVOICE <br /> REQUEST PR# <br /> o LVoG" SR# O07o11U <br /> Z�b3 I� apo Ro# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />