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• t. <br /> U) <br /> SAN JOAQUIN COUNTY <br /> ��. .. ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �" '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.orq/ehd UNIT IV <br /> cq�)FOR �P <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. <br /> 23407001 <br /> Site Location 990 Beechnut Ave Cross Street Forest Hills Dr Cit /State Tracy,Ca 95376 <br /> City/State Zip APN and 23907006 <br /> Property <br /> Owner Chevron EMCAddress 6101 Bollinger Canyon Rd City/State an Ramon, GZip 94583 Phone 925-790-6431 <br /> C-57 Contractor Address City/State Lic Phone <br /> Cons ultant/SubCntrAMEC E&I Address 2101 Webster St, 12 Floor City/StateOakland, CaLic 601450 Phone 510-663-4100 <br /> Billable Party Chevron EMC Address 6101 Bollinger Canyon Rd City/Statean Ramon, p 94583 Phone 925-790-6931 <br /> GIS Coordinates:X Y See attached figure <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING 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.AirSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING E]No C1Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: 990-1, 990-2, 990-3 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS hydrated bentonite grout ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS Wells were constructed w/ bentonite grout. AMEC will pull out tubing and hydrate bentonite to destroy wells. <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signed Title/Company AMSC E&I <br /> Print Name Heidi Dietrich-Foronda Date3/7/14 <br /> Qp DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ( r V �11 AIS 19 <br /> WORK PLAN DATED - 2u.r+R&I Iv Lv/41 <br /> APPLICATION ACCEPTED BY u N'`— DATE I REA /— 99 <br /> GROUT INSPECTION BY FINAL INSPECTION BY y� N/Cw✓1 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 /> REQUEST PR# <br /> 21b 2 $125, 3 (�owv7;c_p 3-ii-iy SR# (,� z/s <br /> 2qv 3 RO# <br /> (3500) <br /> PR# <br /> (2900 <br /> C-57 ✓ WC ✓ WAIVER V C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /1✓ ENCROACHMENT DOCS <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />