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lt✓ SAN JOAQUIN COUNTY ENVIRONMENTAL {-IEALTI-I DEPARTMENT LOP 4t t v :Z,t ": fit 1 SITE MITIGATION 1868 East lia. zelton Avenue, Stockton, CA 95205-6232 UNIT IV Telephone:(209) low 468-3454 Fax:(209)468-3433 Web:vuvv.siaov.ora/ehd Cbl FgR�`t� WELL & BORING PERMIT'APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION bw P66 2390 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 1403 Country Club Blvd. Cross Street Pershing Ave City Stockton Zlp 95204 APN 123-232-46 boo Property Owner Phillips 66 Address 1380 San Pablo Avenue City Rodeo Zip 94572 Phone (510)245.4423 C-57 Conti-actor Gregg Drilling Address 950 Howe Road City Martinez Lic 485165 Phone (925)313-5800 Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave Suite 201 City Modesto Ltc Phone (209)579-2221 t"' Cardno ATC 1117 Lone Palm Ave Suite 201 Modesto 95351 209 579-2221 Billable Party Address City Zip Phone 1 ) GIS Coordinates:X �7 9(pq`I Y `/2 f 3/41 aw CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs s"' 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 t✓ _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑,ROSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT]) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) •_❑INJECTION[.e.AirSoalae.ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 4W CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: I COMMENTS: NOTE: OFFSITE WELLS t&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS •" DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED Q OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS:See attached Workplan 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FTBELOWSURFACE aw TREMIE TYPE TO BE USED:I]AUGERS ❑HOSE I]PIPE ❑MUSHROOM CAP AT L>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 r+ Regulatio d all applica alifornia Laws. j� Signed _ Title/Company �Y"A Io r ,TC—' Print Name J �f��)�L ( Or^nSe` Date O1 Iz3I el .+ DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS qo"L) LIOk Nl77Z� /f/4(13 r :57Zr&V WORK PLAN DATED C9 1 iroBEe 30 2U/ APPLICATION ACCEPTED BY y tv�l ti'uwr DATE ISSUED .2• -/SI AREA—&99 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: >•r ACCOUNTING ONLY: AID/r FAC fA ' PE CODES FEE INFO AMT REMITTED CHECK/A RECV'D BY DATE SERVICE RO to 114VOICE RCQUEST PRiA r 1 3 )/5 $125 r. 6 ( 21 7 CoUSR# COV K ! 1 35 U3 3? RO# 3500 ... ( PR# I (2900 C-57 WC v WAIVER �,H_j/� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT / ,EIVCROACHMENT DOC i f too