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SAN JOAQUIN COUNTY <br /> 2 — ENVIRONMENTAL HEALTH DEPARTMENT <br /> '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> �r<<FOR... Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sicehd.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 820 S.Sacramento Street City/State/Zip Lodi,CA 95240 Phone NA <br /> Cross Street E.Tokay Street APN 045-320--06— 330-o I <br /> PropertyOwner* Lodi Iron Works,Inc. Phone 209-368-5395 <br /> Address 820 S. Sacramento Street eityistate/zip Lodi,CA 95240 <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 Borings/Wells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DW <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 Boflrg Dia: Casing Dia Casing Depth: <br /> ❑ INJECTION IAv Savo,o7mel ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELU SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 2 IN OVER-BORE DIAMETER of 4 inches to depth ofVaries"feet <br /> WELL IDs PRSG-7 and PSG-8 ❑PRESSURE GROUT To depth of_ feet below surface <br /> GROUT SPECIFICATIONS Neat C' ❑EXPLOSIVES From _to feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: Each location will be overdrilled to depth of deep probe.Refer to Table 1 in attached work plan. <br /> 1 hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> �] aquln County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed / Title/Company Principal Geologist/Terra Pacific Group <br /> Print Name Raul BrioneS Date January 26,2016 <br /> DEPARTMENT USE ONLY <br /> /✓��� < /� !/ iG2 Date Issued: <br /> Application Accepted By: w� ,� <br /> Grout Inspection By/Dates: ,411e-Iof�i( �%/�k L�/Jr"41Cwr-J. <br /> Destruction Inspection By/Dates: <br /> Facillt /Site Information <br /> FA NameFA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ©C-57 Authorization for Other to Sign Permit ❑Workers Comp ❑Workers Comp Waiver ❑Encroachment Permit E3 Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Work Plan <br /> Permit 4-7 $130 x 2 2 7 2t 7 Z <br /> EHD 29-01 6-23-2015 Site Mitigation Well Permit Application <br />