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SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.si4ov.org/ehd UNIT IV <br /> 4�%FOR, <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 5429 W Woodbridge Rd Cross Street Ray Road City/State Lodi,CA Zip 95242 APN 011-010-04 <br /> Property <br /> Owner Union Pacific Corporation Address 1400 Douglas Street,Stop 1690 City/State Omaha,NE Zip 68179 Phone <br /> C-57 Contractor Penecore Drilling Address 220 North East Street City/State Woodland,CA Lic 906899 Phone 530-661-3600 <br /> ConsultanUSub Cntr Parsons Corporation Address 2121 N California Blvd,Suite 500 City/State Walnut Creek,Pic 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 SVE-4,SVE-7,SVE-9(4"PVC casing):AS-3(2"PVC casing) <br /> ❑OTHER IDs <br /> TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING S)HOLLOW STEM DIA.OF BOREHOLE 8"to 12" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 3 ®EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS SCH 40 TYPE OF CASING: ❑STEEL El PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 6 ft bgs TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ®PIPE <br /> _❑SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _LEI INJECTION(Le Air Soarae ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with Portland Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 to 32 ft bps ®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, 13 for details on Well Construction and Well Locations <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: ❑ 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 hav repared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and al cable California laws. <br /> Signed Title/Company fp-�dAore-. <br /> Print Name -pt a n� r� e n Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS W, 6)OUD2Xr,F RCA2Z, L0-6/ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY IC 1A Lrl DATE I ,AREA <br /> GROUT INSPECTION BY I FINAL INSPECTION BY DATE '30-x-/ <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 SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Z bl $i,rsX �52�b v qyb Lvlir, SR#Oa 74 fab <br /> ZgDS 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 />