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oA4`'In:: SAN JOAQUIN COUNTY COPY it ENVIRONMENTAL HEALTH DEPARTMENT LOP i 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE/MITIGATION • c4., a'o- Telephone:(209) 468-3454 Fax.(209)468-3433 Web:www.siclov.org/ehd CIRO�� WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JigA/ n a' s NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for permit to construct and/or Install the work described. This application is made i c -`' PP Y q lY P PP �m hatl",,jjth San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. !-R1,i/� 7 Site Location 712 South Sacramento Street Cross Street West Spruce Street City Lodi zip 95240 APN 045-32-;00r'eli`('(-s/f,r Property Owner PG&E Address 3401 Crow Canyon Road City San Ramon zip 94583 Phone 925-383-9517 XXHT(Contractor PIVOX Address 7595 Irvine Center Drive,Suite 152 City Irvine Lic Phone 949-727-1400 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 Allen Parkway,Suite 122 City Irvine zip 92618 Phone 949-297-4444 GIS Coordinates:X IZT4 Y2( . :.74 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE&#OF WELUBORING 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 O.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:ICHECK ALL THAT APPLY) I- #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS:OBS-1 Through 09S-6,SVE-1,SG-2,SG-7 through SG-9,SG-12 through SG-14 ❑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 All soil vapor walls will be removed during remedial oscavallon,and the areas backlilled with clean so%or slurry. 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,�?alAl ap tic b e 2attfvrnla Laws. / Signed � l� � Title/Company_//�r/L�r ✓` /Terra Pacific Group Print Name Rick McCartney Dale_111-II y DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 71 Z S, 5,9dknµ4FN�Z) Sri ,L Ob WORK PLAN DATED Q PD 2 Z 12 APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE _ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID i/ FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE O p © REQUEST PR# ZI`7� $125x7y ( O l �buwTd 1- zl-I�� SR# (kP� 90 RO# 3500 PR# 2900 C-57. // WC tZ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOCwa