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$AN .IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> .y <br /> H i < <br /> • '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •. ;p Tele hone: 209 468-3147 Fax: /209 468-3433 Web:www.siaov.ora/ehd UNIT IV <br /> <<FOiRN p <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> 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 880 Beechnut Ave Cross Street Forest Hills Dr City/State Tracy,CaZip 95376 APN 23407004 <br /> PropertySanEMC 6101 Bollinger Canyon Rd San Ramon, C Phone <br /> Owner Address City/State Ip 94583 925-790-6431 <br /> C-57 Contractor Address City/State Lic Phone <br /> Consultant/SubCntrAMEC E&I Address 2101 Webster St, 12 Floor City/StateOakland, CaLic 601450 Phone 510-663-4100 <br /> Billable Party Chevron EMC Address 6101 Bollinger Canyon Rd City/StatSan Ramon, Cep 94583 phone 925-790-6431 <br /> GIS Coordinates:X Y See attached figure <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <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(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.AirSoarae.Ozone)❑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 /> DESTRUCTION 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: 880-1, 880-2, 880-3 ❑ PRESSURE GROUT TODEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS hydrated bentonite grout ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS Wells were constructed w/ bentonite grout. AMEC will pull out tubing and hydrate bentonite to destroy wells. <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 /> Regulations,,and/all applicable California laws. <br /> Signed ' �°"� Title/Company AMSC E&I <br /> Print Name Heidi Dietrich-Foronda Date3/7/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS q qV 2C{C'IV A,�g <br /> WORK PLAN DATED k 8 ku +k /U,ZLV y <br /> APPLICATION ACCEPTED BY �. SOr11fYK1A In DATE ISSU * Z c.�! -_. �. 6119 <br /> GROUT INSPECTION BY FINAL INSPECTION BY k-kUwl DATE 3'2�•r� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> C ? <br /> REQUEST q PR# <br /> $125, d / > 7 (%Givm SR# <br /> 2 ) (R3 00) <br /> PR# <br /> (2900) <br /> C-57 WC I/ WAIVER A..Ijjw:� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT Af&_ENCROACHMENT DOC AJA <br /> EHD 29-01'5/09/12 WELL PERMIT APP <br />