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SAN JOAQUIN COUNTY <br /> H` — ENVIRONMENTAL HEALTH DEPARTMENT <br /> '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> • d9<iFbdl'�~ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.socehd.com <br /> SITE MITIGATION 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. <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 712 S.Sacramento Street City/State/Zip Lodi,CA 95240 Phone NA <br /> Cross Street E.Tokay Street APN 045-320-06 <br /> Property Owner' Pacific Gas and Electric Company Phone 925-383-9517 <br /> Address 3401 Crow Canyon Road cityistate/zip San Ramon,CA 94583 <br /> C-57 Contractor Gregg Drilling&Testing License# C57 485165 Phone 925-313-5800 <br /> Address 950 Howe Road City/State/Zip Martinez,CA 94553 <br /> Consultant/Sub-contractor Terra Pacific Group License# 885321 Phone949-297-4444x223 <br /> Address 13900 Alton Parkway,Suite 122 city/state/zip Irvine,CA 92618 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Bodngs/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(VaporMater) ❑ HAMMERCRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes❑No Bonng Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(zu Soyoo.Oza+ol ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freetall Depth Is 30 Ft) <br /> WELL/SOIL BORING Ds GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 6 19 OVER-BORE DIAMETER of 4 inches to depth ofVaries"feet <br /> WELL IDs PRSG-1 through PSG-6 ❑PRESSURE GROUT To depth of_ feet below surface <br /> GROUT SPECIFICATIONS Neal .emeflt ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [I AUGERS ❑HOSE FK]PIPE ❑MUSHROOM CAP ❑3 feet below surface or feel below surface if>3 feel <br /> COMMENTS: Each location will be overdrilled to depth of deep probe.Refer to Table I in attached work plan. <br /> I hereby certify that I am authorized to complete this application and that the work will be done In accordance with <br /> Sa aquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signe Title/Company Principal Geologist/'Terra Pacific Group <br /> Print Name Ratti riones Date January 26,2016 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: G ;fid Date Issued: <br /> Grout Inspection By/Dates: /t//C ✓Soft 2 <br /> Destruction Inspection By/Dates: <br /> Facllit !Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑t-57 Authonzalion for Other to Sign Pennil 13 Workers Comp ❑Workers Comp Waiver ❑Encroachment Permll ❑Access Agreement ❑'Leae Agency Approval [)MFR <br /> COMMENTSICONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan 6 <br /> Permit z�pZ 31 $130x <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />