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ONSrpC COP <br /> "� " <br /> L1 <br /> a°�'l�•. SAN JOAQUIN COUNTY t <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> . �q..- -:-..• Telephone:(249)468-3454 Fax:(209)468-3433 Web:www.sictov.orp/ehd <br /> �I�ORa <br /> two <br /> WELL. & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> P66 2390 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> dw 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 /> r Owner Address City Zip Phone ( ) <br /> C-57 Contractor Gregg Drilling Address 950 Howe Road City Martinez Lie 485165 Phone (925)313-5800 <br /> ConsultantiSub Cntr Cardno ATC Address 1117 Lone Palm Ave Suite 201 City Modesto Lie 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 /> ter <br /> GIS Coordinates:X 37• G9 Y 't Z/, •3fry 7 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> aw D NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> D SOIL BORING IDS <br /> D WELL IDs <br /> D OTHER IDS <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _D MONITORING D HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water D HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC O OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE D PIPE <br /> r -.—D SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —D INJECTION fi.e.AirSome.ozone)D HAND AUGER GROUT SPECIFICATIONS <br /> —D OTHER: D OTHER: APPROX.BORING DEPTH D BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> CONDUCTOR CASING D No D Yet:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> ..rP4 #OF WELLS)TO BE DESTROYED pp OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDS:See attached Workplan N PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS D EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:®AUGERS D HOSE ®PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> r <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 app Ica gallfornia Laws. <br /> Signed _ Title/Company cla-IrA no AT c-- <br /> Print Name tl ,n n,- 4 Quf1^SR-`I Date o 1 1-13 IJ41 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS_ "yo-J �oGc�T2Y CfLi,� STG��CT�� <br /> WORK PLAN DATED �7bBF/'t gy f 7 3 J <br /> APPLICATION ACCEPTED BY 4. UN, KLtIvJ DATE ISSUED_I`Z• AREA 16 9q <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR i/ <br /> 35oZ $125X2( 2 � dun. /���-iU SR# 4, Wg7 <br /> 3r�v3 3 75 325 RO# <br /> (3500) <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT_ _ENCROACHMENT DOC &/4_ <br />