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` • CRIGINA .- 4 SAN JOAQUIN COUNTY ? ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV Q d[I Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.sigov.org/eh 5 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED the work d. s application is made in Joaquin llComy Development TdIe,Ioaquin Chom spie County9-1115.3,and the(Sta dads ofto Construct the San JoancVor quin n County Environmental lHealth Department. c GT cOVJ Site Location 437 East Minor Ave Cross Street cei6omfa street City/State Stockton,CA Zip 95202 APN Property 6111 Borkper Canyon Rd.Room 3652 cityistate San Remon,CA Zip 94583 Phone 9255 3�23a9 Owner chevron Environmental Management Address Uc 936110 Phone 91683&1169 3000 30U Street CirylSlate Weal Sec'CA C•57 Contractor Cascade Drilling LLC Address 91G]860320 101 Creenede Ridge Coud,Sulle 200 City/Stale Roeaeilla,CA Lic Phone ConsultanUSub Cntr ARCADIB U.S.,Inc. Address Phone A2Adp,L ILS. /hG. Address Ciry/Stale ZP Billable Pally -121. 7y0 GIS Coordinates:X 9%Cry Y CONSTRUCTION WORK TO BE PERFORMED: []NEW WELLIBORING(CPT,GEOPR08E,HVDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS MIJ❑L STEE E WELL❑PVC OSING O HER_ _I]EXTRACTION:vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE IL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —[I SO GROUT SPECIFICATIONS ❑INJECTION r 4i Stance,Ozone/❑HAND AUGER ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE —[]OTHER: ❑OTHER: APPROX.BORING DEPTH CONDUCTOR CASING❑No❑Yes:Casing Dia:_Casing Depth:_ Boring Dia:__ COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ESTRUCTION WORK TO) O BE PERFORMED: DESTRUCTION METHOD:fCHECKALL THATAPPLYI D I #OICTION)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: a.r.w.u.o,u.m,ule,u.n,uu.wo,u.m,uxi,us,u.m.ua..uss.sysaec,s>.uac.nr.x.amvne ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS n••=•^-" O EXPLOSIVES FROM e«m TO •aitlse4 FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS Sea blast Riga for indbiiijual well explosive 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,and all applicable California laws. Title/Company Project Scientist/ARCADIB U.S.,Inc. Signed Date September 5,2014 Print Name Juli .Munn DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 1437 C. r4/61-ft? &K SpcC CV04) -- WORK PLAN DATED S6 P7Z-m (a O APPLICATION ACCEPTED BY l °foFlkNwl DATE ISSUED (-y5-/y AREA G 4 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE C OM MENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# 3S0 $,3ox23 IL 4 CIs7u ✓�2 �f- (wS Ll SR# 20 RO#g0-5'8 2 350 PRR#390 3 # 2900 C-57 V WC V _WAIVER M A C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_,0-- WELL WELL PERMIT APP EHD 29-01 7/24/14