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:��'" � , SAN 10A0UIN a (� � Environmental Health Department COUNTY— e /��) IN)r� Greatness 91'ows here. (� eWID O,� 5V SITE MITIGATION WELL & BORING PERMIT APPLICATION VV I < < bP For Wells and Borings Used for Contaminant Investigations and Remediation r4 lYed NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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 San Joaquin County Well Standards. Job Address 5300 W:Woodbridge Rd. City/State/Zip Lodi, CA 95242 Phone Cross Street N. Ray Road APN 011-160-25 O: 925-415-6852 Property Owner* Pacific Gas and Electric (Bob Gray) Phone M: 415-265-0926 Address 3401 Crow Canyon Road City/State/Zip San Ramon, CA 94583 C-57 Contractor Cascade Drilling, LLC License# 1058336 Phone 209-570-7235 Address 3451 Collins Ave. City/State/Zip Richmond, CA 94806 Consultant/Sub-Contractor Jacobs Engineering Group,Inc. (Jonathan Ferris) License# Phone 505-280-9088 Address 155 Grand Ave. Suite 800 City/State/Zip Oakland, CA 94612 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(AirSparae,Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 24 ® OVER-BORE DIAMETER of 10 inches to depth of up to 32 feet WELL IDS See attached table. ® PRESSURE GROUT To depth of up to 32feet below surface (Wells have different depths) GROUT SPECIFICATIONS Type 1/11 Portland Cement ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑x AUGERS ❑ HOSE © PIPE ® MUSHROOM CAP ® 3 feet below surface or feet below surface if>3 feet COMMENTS: Wells to be overdrilled include-SVE-1,VW-2, SV-4,ASA, and BS-1. Wells located less than 5 feel of known utilities(required by Cascade and PG&E)are to be destroyed by pressure grouting Wells to be pressure grouted include-AS-1,AS-2, OS-1,OS-2,OS-3, OS-4, OS-5,OS-6, OS-7, OS-8, SV-5, SV-7, SV-8, SVE-2,SVE-3, SVE-5,SVE-6,VW-1,VW-3 The upper 3 feet will be removed and completed with a mushroom cap of cement and with backfll of native material to surface. I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Signed Title/Company Project Manager/Jacobs Engineering Group, Inc. Print Name Jonathan Ferris Date May 6, 2021 DEPARTMENT USE ONLY Application Accepted By: JEFFREY WONG D�atenlss,,ued: 5/7/2021 (revised 6/2/2021; 6/4/2021) Grout Inspectors By/Ly'dteZ ✓� - (9-L d eM0 , itrr it Waz I Destruction Inspection By/D es: s we' 0 Q re- — S -L� Ifl Facilit /Site Information - CV J. Is FA Name GE LAS VINAS WELL ABANDONME AAddress 5300 WOODBRIDGE FA# F90007474 PR# PR0506524 �vl 2960 �t ? FA PE WP Reviewed By JW Work Plan Date 3/9/2020 + new maps -QA►14a'4/ ❑ C-57 IN C-57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑ Lead Agency Approval 0 MFR IO�tf7✓ COMMENTS/CONDITIONS: EHD agrees to revision by email dated 6/1/2021 requesting variant to pressure grout AS-4, BS-1, VW2, and complete removal 21 of the tubing in SV-4 before air knifing to 3' bsg and backfilling. SVE1 must still be overdrilled (but at a later date due to proximity to a bird's nest. -JW EHD agrees to 2nd revision request dated 6/4/2021 to pressure grout SVE2 to 20'bsg instead of 25' bsg. -JW WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV D BY DATE W1ELL PERMIT# INVOICE# Permit 2902 313 $152x 5 760 cc JW 5/5/2021 Wp0042015 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 488-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-0105-01-17 Confirmation # 124904343 SR0083673 Site Mitigation Well Permit Application