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SAN JOAQUIN COUNTY CRIGINA o�,. ... —lu" �z ENVIRONMENTAL HEALTH DEPARTMENT LOP W. X • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �q•.. �:P.• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siclov.org/ehd UNIT IV ��Foa 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. 23407001 Site Location 990 Beechnut Ave Cross Street Forest Hills Dr City/State Tracy,CaZip 95376 APN and 23407006 PropertySanEMC San Ramon, G� 94583 925-790-6431 Owner Address 6101 Bollinger Canyon Rd City/State Ip Phone C-57 Contractor Address City/State Lic Phone Consultant/SubCntrAMEC E&I Address 2101 Webster St, 12 Floor City/StateOakland, CaLic 601450 Phone 510-663-4100 Billable Party Chevron EMC Address 6101 Bollinger Canyon Rd City/State Ramon, Cp 94583 Phone 925-790-6931 GIS Coordinates:X Y See attached figure CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(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 & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELLIDs: 990-1, 990-2, 990-3 ❑ PRESSURE GROUT TODEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS hydrated bentonite grout ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS wells were constructed w/ bentonite grout. AMEC will pull out tubing and hydrate bentonite to destroy wells. 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,.�a,/nd all applicable California laws. 9 Si ned /` - Title/Company AMEC E&I Print Name Heidi Dietrich-Foronda Date3/7/14 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS � 7p V �K'V47- 4C/6- WORK PLAN DATED - R.k I(> Zt�I y APPLICATION ACCEPTED BY 4u irtl_ DATE IS ,/&,-LTJ .AREA /699 GROUT INSPECTION BY FINAL INSPECTION BY I LALvr1 DATE ?" 74`'f DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 210 2, $125, 3 33�r 3�G dot"VW 3-11-1q SR# (o z/s r� RO# (3500) PR# (2900) C-57 ✓ WC ✓ WAIVER ..A)1�-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP