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,oPo" •�° SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �� < LOP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION E4P • �9..- �,.•;P.° Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.s" ov.or /eh UNIT IV + CrFOR� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO NOV 0 4'2013 I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �IVV j Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i's � f with San I Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depa �6 SIAL HEALTH PERMIT�JS (ICES Site Location 712 South Sacramento Street Cross Street West Spruce Street City Lodi zip 95240 APN 04 c_jo(:, Property I Owner PG&E Address 3401 Crow Canyon Road City San Ramon zip 94583 Phone 925-383-9517 C-57 Contractor National EWP Address 1961 Meeker Avenue City Richmond Lic 953646 Phone 510-236-6282 Consultant/Sub Cntr Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine Lic 885321 Phone 949-297-4444 Billable Party Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine zip 92618 Phone 949-297-4444 GIS Coordinates:X . 12 Y (z/, 272. CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDS ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: 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 R OVER-BORE DIAMETER OF 6 INCHES TO DEPTH OF e.s(e)&15(2)FT WELL IDS:SG-1.SG-3 through SG-6,SG-10.SGA 1 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neal Cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:N AUGERS ❑HOSE X PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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,ai?yallapplicable California_Laws. Signed Title/CompanyPf1,, /1c C / W /Terra Pacific Group Print Name Rick McCartney / Date 10— 31 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 7 1 2 5 , S�e ✓�^�C�7o ST! (��j/ WORK PLAN DATED CD 4 TU 8e—R I� ' 7-nt 2- APPLICATION ACCEPTED BY C�r;;,K U f✓Y DATE ISSUED 11-54AREA /679 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID It FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUESTQcP�R# oZ o? $125 x 7 811 CTI �,u ry rE I f c- SR# 6 1 �U RO# 3500) PR# (2900 C-57 WC r/ WAIVER A/ Kl C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !� ENCROACHMENT DOC i(i,y