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SAN JOAQUIN COUNTY FILE C ENVIRONMENTAL HEALTH DEPARTMENT LOP y` 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION IV Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orpleh �/Foa WELL 8t: BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ay5330-U/ Site Location 820 South Sacramento Street Cross Street West Spruce Street City/State Lodi yip 95240 APN_04'5"&�- Property Lodi Iron Works,Inc. 820 South Sacramento Street Lodi 95240 209-368-5395 Owner Address City/State Zip Phone C-57 Contractor Cascade Drilling,LP Address 3000 Duluth Street City/State W.Sacramento Lic C57-938110 Phone 916-638-1169 Consultant/Sub Cntr Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City/State Irvine Lic 885321 Phone 949-297-4444 Billable Party Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City/State Irvine Zip 92618 Phone 949-297-4444 GIS Coordlnates:X 3,1f./Zlr Y —1-A, 1. 2 72.78 CONSTRUCTION WORK TO BE PERFORMED: NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS M OTHER IDS PRSG-7 and PRSG-8 TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA; 1/4' _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ® OTHER Teflon 2 9 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 4.5' bgs TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes B No(MAXIMUM FREE FALL DEPTH IS 30 FT) _,❑INJECTION(i.e.Air Scarce,ozone)E HAND AUGER upper 5 feet GROUT SPECIFICATIONS Neat Cement with 5%Bentonite ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 8.5'bgs 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING M No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:see attached Table 4 and Figures 2 and 4 for construction and location details NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS - — - — - — — —- ❑EXPLOSIVES-FROM--- -- 11 - FTBELOW-SURFACE- TREMIE TYPE TO BE-USED:-[]AUGERS -HOSE-❑-PIPE- - --❑-MUSHROOM CAP-AT L3 FTS- ---.— FT-BELOW-SURFACE--- COMMENTS TBELOWSURFACE —COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations and al a Ii b e California laves. (� Signed V�Y 1L.*'_1 Title/Company Principal Engineer/Terra Pacific Group Print Name Matt Derby Date�� 7 DE ARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS //Z S, / Q/�MF�Ta Sl.. 40D/ WORK PLAN DATED ./,4w APPLICATION ACCEPTED BY J.Yr,r2-K�w1 DATE ISSUED �-�G��S— AREA "r,99 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COM MENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST 77 PPR# p / $130x 2- 240 b � IUGy C�u►vjEfZ SR# 7/ 370 Ze(U 2) 3�0 3�� (300 PR# (2900 C-57 ✓ WC ✓ WAIVER N t}-- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_& EHD 29-01 7/24/14 WELL PERMIT APP