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SAN JOAQUIN COUNTY � nnv <br /> �. . •.oIS <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: a <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> �;.. :�;;P• Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orglehd UNIT IV <br /> ��FOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. bdo <br /> Site Location 712 South Sacramento Street Cross Street West Spruce Street Cit, Lodi zip 95240 APN 045-32lo90 <br /> Property <br /> Owner PG&E Address 3401 Crow Canyon Road City San Ramon zip 94583 Phone 925-383-9517 <br /> C-57 Contractor National EWP Address 1961 Meeker Avenue City Richmond Lic 953646 Phone 510-236-6282 <br /> Consultant/Sub Cntr Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine Lic 885321 Phone 949-297-4444 <br /> Billable Party Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City Irvine zip 92618 Phone 949-297-4444 <br /> GIS Coordinates:X 38` 0-6 Y —f 2 f A,7 3 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> X SOIL BORING IDs B-104 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑� SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT To DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,andid'A applicable California Laws. <br /> y <br /> Signed Title/Company Zrr Imo/ /Terra Pacific Group <br /> Print Name Rick McCartney <br /> Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS ! 5. SA(?R/t/t'� sil , )4go r <br /> WORK PLAN DATED OCI TD E2 I ! Z <br /> APPLICATION ACCEPTED BY J -`la(4K u k- DATE IS r."+z EA 16/9 <br /> V' <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> p q <br /> REQUEST <br /> PRq# <br /> I D Jr $ 125 x / 2C z CfSR# 6C)4/( <br /> RO# <br /> (3500 <br /> PR# <br /> (z9oo> <br /> C-57 I, WC __WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC f9 <br />