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SAN JOAQUIN COUNTY ENVIrtONMENTAL HEALTH DEPARTNI—J Lop I 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV SFr pi 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. Site Location 712 South Sacramento Street Cross Street West Spruce Street City/State Lodi,CA Zip 95240 APN 045-320-06 Property Owner PG&E Address 3401 Crow Canyon Road City/State San Ramon,CA Zip 94583 phone 925-383-9517 C-57 Contractor Gregg Drilling&Testing Address 950 Howe Road City/State Martinez,CA Lic C57-485165 Phone 925-313-5800 Consultant/Sub Cntr Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City/State Irvine,CA Lic 885321 Phone 949-297-4444 Billable Party Terra Pacific Group Address 13900 Alton Parkway,Suite 122 City/State Irvine,CA InduAnp40. 7 444 GIS Coordinates:X 38.12675 Y -121.27260 T% maw Now CONSTRUCTION WORK TO BE PERFORMED: JAN 2 0 2018 ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs �►w wdV�uulowrT�L l7CIY.,17 El IDs �sUR*M =00, ❑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(i a Air Soarae.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 ❑■ OVER-BORE DIAMETER OF 4 INCHES TO DEPTH OF VARIES"FT WELL IDs: PRSG-1 THROUGH PRSG-6 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS NEAT CEMENT [:1 EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: E]AUGERS E] HOSE XPIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS **FAC'H I OC ATION TO BF OVFR-DRILLED TO DFPTH OF nFFP PROBF RFFFR TO TABLE 1 IN ATTAC:HFD WORKPLAN . 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,an plica ornia laws. Signed �' Title/Company Principal Geologist/Terra Pacific Group Print Name RAUL BRIONES Date 1/13/16 DEPARTMENT USE ONLY ��Gl � wv? SITE MAP IN UNIT IV FILE-SITE ADDRESS U WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY 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 REQUEST PR# $ 130 x 6 S R# RO# (3500) PR# (2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP