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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ORIGINA1L 1868 Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.ora/eh LOP SITE MITIGATION UNIT IV WELL & 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. p yS—_32U -U Co Site Location 712 South Sacramento Street Cross Street West Spruce Street City/State Lodi Zip 95240 APN 04F-22"eta Property Owner PG&E Address 3401 Crow Canyon Road C-57 Contractor Cascade Drilling, LP Address 3000 Duluth Street Consultant/Sub Cntr Terra Pacific Group Address 13900 Alton Parkway, Suite 122 Billable Party Terra Pacific Group Address 13900 Alton Parkway, Suite 122 GIS Coordinates: X 38. 0,47S Y 'r21-Z7ZG�C> City/State San Ramon Zip 94583 Phone 925-383-9517 City/State W. Sacramento Lic C57-938110 Phone 916-638-1169 City/State Irvine Lic 885321 Phone 949-297-4444 City/State Irvine Zip 92618 Phone 949-297-4444 CONSTRUCTION WORK TO BE PERFORMED: AID # Q NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑ SOIL BORING IDS FEE INFO AMT REMITTED ❑ WELL IDs RECV'D BY DATE © OTHER IDS PRSG-1 through PRSG-6 I RO # PR # 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 6 ® SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL 4.5' or 6.5' bgs TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE _❑ SOIL BORING 19 PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (i.e .Air Soarce. ozone) B HAND AUGER upper 5 feet GROUT SPECIFICATIONS Neat Cement with 5% Bentonite ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH see Table 4 8 BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ® No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: see attached Table 4 and Figures 2 and 4 for construction and location details NOTE: OFFSITE WELLS 81 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 TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (?3 FT) FT BELOW SURFACE 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 Regulatlo and Icable California laws. Signed w, D,, Title/Company Pincipal Engineer / Terra Pacific Group Print Name Matt Derby Date ( DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS 7ZZ Sr I&Ikril' 6y7,n 52aEr, AZZI N DATED _ APPLICATION R`CCEPTED BYJ�NJ-I JD RKu�i DATE I D` /' /�+ EA_ 16 19' GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMM F NTSICnNDITI0NS* FINAL INSPECTION BYI DATE DATE �r_•�! ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST I RO # PR # INVOICE S130X (P Igo %1 (-)(j �vUrv�2 s SR# 7/3yq 5v 3 3�0 3qo (33500 PR # (2900) C-57 WC ✓ WAIVER /" A- G -S/ LE I I EK Ut- AU I t1UKILA I MN I U WUN I LKIVII I (/ CIVL.RUHLrllvICIV I vUi EHD 29-01 7/24/14 WELL PERMIT APP