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ON S1M- <br /> oP°•''•'•• SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> V. 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> SITE MITIGATION <br /> • •..- <br /> Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.siaov.oralehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> P662390 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 /> Site Location 1403 Country Club Blvd. Cross Street Pershing Ave City Stockton Zip 95204 APN 123-232-46 <br /> Property Phillips 66 1380 San Pablo Avenue Rodeo 94572 510 245-4423 <br /> Owner p Address City Zip Phone � ) <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 <br /> Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave Suite 201 City Modesto Lic Phone (209)579-2221 <br /> Billable Party Cardno ATC Address 1117 Lone Palm Ave Suite 201 City Modesto Zip 95351 Phone (209)579-2221 <br /> GIS Coordinates:X 3? C1691 Y -/Z 1. 3 f S 7 <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 8,#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DtA: <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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION fi.e AirSoarae.Ozortel❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> STRUC ION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs:See attached Workplan IN PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:©AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 /> Regulatio , d all applicable California Laws. <br /> Signed _ Title/Company Cj�ard►,o / `T�— <br /> Print Name Date 01 4-3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I10 S 2ZIC-6lu <br /> WORK PLAN DATED CD e S V ZU 7 3 a <br /> APPLICATION ACCEPTED BY J d i4IC u DATE <br /> GROUT INSPECTION BY FINAL INSPECTION BY •G(' / <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: t1t <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 3502 $125x ;> �aW74P- SR# �S <br /> RO# <br /> 353 �S 3,•S 3500 ` <br /> PR# i <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT—_ENCROACHMENT DOC &Z4 E <br /> I <br />