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PaUfN SAN .IOAQUIN COUNTY FILE CCPV ENVIRONMENTAL HEALTH DEPARTMENT LOP y �X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . •..- 1 :.•;P (/ � 1209 468-3454 Fax: //209 468-3433 Web:www.s' ov.or leh UNIT Iv Telephone: p 1 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO NOV 04-2013 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Iv Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is rp�� +Arumo)je,R tthSaan�T� Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depa ti tUIVIVItIV t PERMII�J F& ICES Site Location 712 South Sacramento Street Cross Street West Spruce Street City Lodi zip 95240 APN 04 c�oC,, Property 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 Cit, 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 3 8. 1 K Y —(?-/ , z 2 2 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 W ELL(S)TO BE DESTROYED ❑■ OVER-BORE DIAMETER OF 6 INCHES TO DEPTH OF e.&(s)&is(z)FT WELL IDS:SG-1,SG-3 through SG-6,SG-10,SG-11 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:9 AUGERS ❑ HOSE H 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,a ll applic ble California Laws. Signed Title/Company Pr,,C,,/lc,.p( / /Terra Pacific Group Print Name Rick McCartney T Date /0— DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 7 /2 5'- S�C' /�n a�iV7c, �/ L!J b/ WORK PLAN DATED (n e TU R(—'Q I I" ZU/Z CQIWZL`Z..�P' 1, E",;;,) APPLICATION ACCEPTED BY Cy✓i KU 1'4-Y DATE IS UE AREA GROUT INSPECTION BY FINAL INSPECTION BY L441 DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE p REQUEST I PR# O z $ 125 x 7 U�y 1 (1 LA ru TIE( I ( L_ S R# RO# 3500 PR# (2900 C-57 WC ✓ WAIVER dl n C57 LETTER OF AUTHORIZATIOIQ TO SIGN PERMIT r, ENCROACHMENT Doc Xi