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1 SANJ0A0UIN Environmental Health Department (_d :_' ") —COUNTY— _ /^/ / I�eW ,7prYy�l"l 4C Greatness grows here. I� 1 �0.J'v 1, 9 " d2w10 o�- S✓t ' I SITE MITIGATION WELL & BORING PERMIT APPLICATION V"If ' I( For Wells and Borings Used for Contaminant Investigations and Remediation III"(re J 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/Stateizip 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 Jambs Engineedng Gmup,lnm(Jomffian Fenls) License# Phone 505-280-9088 Address 155 Grand Ave. Suite 800 City/State/Zip Oakland, CA 94612 CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNJells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX El STOVEPIPE ❑ EXTRACTION(vaporMater) ❑ HAMMERIDRNEN DIA.OFBOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOILVAPORPROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL El PVC ❑ OTHER ❑ SOILBORING ❑ PUSH POINT(GP/CPT) CONDUCTORCASING ❑Yes ❑No Boring Die: Casing Dia: Casing Depth: ❑ INJECTION tasiaxe000wl ❑ HANDAUGER GROUTSEALDEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefell Depth is 30 Ft) WELUSOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLYI #WELLS TO BE DESTROYED 24 ®OVER-BORE DIAMETER of 10 inches to depth of up to 32 feel WELL IDs See attached table. ®PRESSURE GROUT To depth of u0 to 32feel below sudace (Wells have different depths) GROUT SPECIFICATIONSTvoe l/Il Portland Cement [_1 EXPLOSIVES From_to_feet below surface TREMIE TYPE TO BE USED AUGERS ❑HOSE ®PIPE ®MUSHROOM CAP ®3 feet below surface or feet below surface if>3 feel COMMENTS: Wells to be overcI lied Include-SVE-1,VW-2,SVA ASA and BS-1. Wells located less than 5 feet 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-2,08-1,OS-2,OS .OS4,0S-5,OSS,0S.7,OS-S,SV5,SV-7,SV-a,SVE-2,SVE-3.SVES,SVES,V W-1,V W-3 The upper 3 feet will be removed and completed with a mushroom cap of cement and with backfil of native material to surface. 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. Jonathan Ferris Print Name Date May 6, 2021 DEPARTMENT USE ONLY Application Acce/pted By: JEFFREY WONG Date Issued: 5/7/2021 (revised 6/212021; 614/2021) Grout Insp1c6oA7i By/bdte : V& — O'L✓tm O , • tt _ ic Destruction Inspection By/D es: S W 0 C — / Facilit /Site Information Y ell ; , S' FA Name GE LAS VINAS WELL ABANDONME TAAddress 5300 WOODBRIDGE FA# F 0007474 r PR# PR050*6524 2960 per' FA PE WP Reviewed By J W Work Plan Dale 3/9/2020 + new maps LA141 ❑C57 G57 Authorizatlon for Other to Sign Permit ❑Wodeers Comp ❑Wodeers Comp Waver ❑Enaoachmenl Penng ❑AccessAgreemenl ❑teed Agency Approval MFR /Ol COMMENTSICONDITIONS: EHD agrees to revision by email dated 6/1/2021 requesting variant to pressure grout AS-4, BS-1, VW2,and complete removal 2I 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' is JW WP TYPE I PE SC FEE INFO AMT RENHTTEDj CHECK# I RECV'D BY DATE WELL PERMIT# INVOICE# Permit 2902 313 g152x 5 760 1 CC I JW 5/5/2021 1 wp0042015 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 I F 209 464-0138 1 www.sicehd.com EHD29410 l-n Confirmation # 124904343 SRO83673 Site Mitigation Well Permit Application