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PQM(" SAN JOAQUIN COUNTY ENVIKONMENTAL HEALTH DEPARTML_. . f LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION oq�/FORN•P' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:Wwwsiclov.ora/eh UNIT IV 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 820 South Sacramento Street Cross Street West Spruce Street City/State Lodi,CA Zip 95240 APN 045-330-01 Property Owner Lodi Iron Works, Inc. Address 820 South Sacramento Street City/State Lodi,CA Zip 95240 Phone 209-368-5395 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 Zip 92618 Phone 949-297-4444 GIS Coordinates:X 38.12622 Y -121.27278 RECEIVED CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) JAN 2 0 20% ❑ SOIL BORING IDs ❑WELL IDs ❑ OTHER IDs M TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS PERMIT i'- _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl 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 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) 2 #OF WELLS)TO BE DESTROYED ❑■ OVER-BORE DIAMETER OF 4 INCHES TO DEPTH OF VARIES**FT WELL IDs: PRSG-7 AND PRSG-8 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS NEAT CEMENT ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑■ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS **EACH LOCATION TO BE OVER-DRILLED TO DEPTH OF DEEP PROBE. REFER TO TABLE 1 IN ATTACHED 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 applic alifornia laws. Signed Title/Company Principal Geologist/Terra Pacific Group Print Name RAUL RIONES Date 1/13/16 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS l lI All t 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# $ 130x2 SR# 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