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, `''" '*Age SAN JOAQUIN COUNTY •.� ORIGINAL 2' ENVIRONMENTAL HEALTH DEPARTMENT LOP • ^ "";:• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •. P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd UNIT IV �L4FOa 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 139 South Center Street Cross Street East Washington Ave City/StateStockton,CA Zip 95202 APN 13730012 Property Ciryof Stockton Owner (Housing and Redevelopment) Address 425 N.EI Dorado Street,3rd Floor City/State Stockton,CA Zip95202 Phone (209)937-8539 C-57 Contractor ABC Liovin Drilling.Inc. Address 1180 East Burnett Street City/State Signal Hill,CA Lic 422904 Phone 562-981-8575 Consultant/Sub Cntr AEC OM Address 901 Via Piemonte,5th Floor City/State Ontario,CA Lic 641639 Phone 909-579-3981 Billable Party s Chevron EMCAddress 6101 Bollinger Canyon Road City/StateSan Ramon,CAZip94583 Phone 925-790-6581 GIS Coordinates:X 37. 7� 057 Y —17.1. A9077 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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.e,AirSparge.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 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 12 #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER of 8-10" INCHES TO DEPTH OF 30-105 FT WELL IDs: MW-(3,5,6,7,8,13,14,15,15D,16,17,1SD2) ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:El AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 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,and all applicable California laws. Signed a1/___1 1/ Title/Company Project Geologist/AECOM Print Name Alonzo Poach Z57 Date 7/22/2014 p DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS • CSE N 5TP—, T 1 WORK PLAN DATED Ju L. I tir Z0/ APPLICATION ACCEPTED BY .I.yOF}Jl'uM DATE I ( REA�r l GROUT INSPECTION BY FINAL INSPECTION BYDATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# , RECV'D BY DATE SERVICE RO# INVOICE Q REQUEST PR# �i0 2 $125x /Z f'U 7`j T 7 Z/-�� SR# O / 3 00 PR# (2900) C-57_ WC _WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC�tJ EHD 29-01 5/09/12 WELL PERMIT APP