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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT CRIG1. LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone. (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.org/eh 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. dys,�3o ^U Site Location 820 South Sacramento Street Cross Street West Spruce Street City/State Lodi Zip 95240 APN '045'62-fi-,—__ Property Owner Lodi Iron Works, Inc C-57 Contractor Cascade Drilling, LP Consultant(Sub Cntr Terra Pacific Group Billable Party Terra Pacific Group Address 820 South Sacramento Street Address 3000 Duluth Street Address 13900 Alton Parkway, Suite 122 Address 13900 Alton Parkway, Suite 122 GIS Coordinates: X W, / 9-(r ),)- Y --1-2 /. 2 29-78 CONSTRUCTION WORK TO BE PERFORMED: H NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, ❑ SOIL BORING IDs ❑ WELL IDs ❑� OTHER IDS PRSG-7 and PRSG-8 TYPE & # OF WELL/BORING INSTALLATION TYPE _❑ MONITORING ❑ HOLLOW STEM _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN 2 0 SOIL VAPOR PROBE ❑ MUD ROTARY HAND -AUGER, OTHER) City/State Lodi City/State W Sacramento City/State Irvine City/State Irvine Zip 95240 Phone 209-368-5395 Lic C57-938110 Phone 916-638-1169 Lic 885321 Phone 949-297-4444 Zip 92618 Phone 949-297-4444 CONSTRUCTION SPECIFICATIONS DIA. OF BOREHOLE 3„ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 1/4" CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC N OTHER Teflon 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) M HAND AUGER upper 5 feet GROUT SPECIFICATIONS Neat Cement with 5% Bentonite ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 8.5' bgs CONDUCTOR CASING M No ❑ Yes: Casing Dia COMMENTS: sea attached Table 4 and Figures 2 and 4 for construction and location details R BOLTED TRAFFIC BOX OR ❑ STOVE PIPE Casing Depth: Boring Dia: 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 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 Regulations and al ap II b e California lavKs. (1 Signed W� J•L�� Title/Company Principal Engineer/ Terra Pacific Group Print Name Matt Derby Datel,,�� DE14ARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS / 12 5, Jr,Q_41 ,E,yTD S% /,o, i WORK PLAN DATED 15 APPLICATION ACCEPTED BY.�• `/, t�KKw1 DATE I _� D 1.14w," ""#AREA' /69q GROUT INSPECTION BY FINAL INSPECTION BY Ell ,((4 DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE REQUEST RO # PR # INVOICE U I $130- Z X40 \ d 2z q CI, unii�iZ /h-/ � SR# zct0 1:1 390 (300 (3500) PR # 2900 C-57 ✓ WC ✓ WAIVER N Yt - C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT , ENCROACHMENT DOCS" EHD 29-01 7/24114 WELL PERMIT APP