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• ORIGINAL �4�Iy SAN JOAQUIN COUNTY 61VSIT( >.•�s 2 ENVIRONMENTAL HEALTH DEPARTMENT LOP cr .� SITE MITIGATION '•��Ik , 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV 4 p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:WWw.sinoV.oraleh /Fpr 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. Site Location 437 East Miner Ave Cro95 Street California Street City/Stale Slocidw.CA Zip 95202 APN 139-24-017 Property City/State Sen R--,CA Zip 94563 Phone 9'25-5 -2349 Owner Chevron EnNronmental Alane9amenl Address 6111 Bollinger Carryon Rd,Room 3652 Cascade Drilling LLC 3000 Dulule Street City/Stale Weal Sac.CA LiC 938110 Phone 91663&1169 C-57 Contractor Address ConsultantlSub CnV ARCADIS U.S..Inc. Address fol Dreeh&de Ridge coon,smta 200 City/State RouMna,GA Lic Phone 916486-03213 Billable Pally ARCADIS U.S..Inc Address M.tove City/State Zip Phone GIS Coordinates:X$7.95474 V -/2f•3n SG8 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER.OTHER( ❑SOIL BORING IDS ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _(]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vaporl Water [IHAMMER/ORNEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE [IMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [IPIPE _❑SOIL BORING [I PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[I INJECTION f• 15 a OWAI❑HAND AUGER GROUT SPECIFICATIONS _ OTHER: APAPPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE ❑OTHER: CONDUCTOR CASING[I No❑Yes:Casing Dia: Casing Depth:_ Boring Dia;_ COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO 8E PERFORMED: DESTRUCTION METH OD: CHECK ALL THAT APPLY) 56 #OF WELL(SJ TO BE DESTROYED ISVP-1N8:2AIB:3A18.-4A/B,5418.6AIB,dA1B;6NB) + OVER-BORE DIAMETER OF a INCHES TO DEPTH OF 2a FT FT BELOW SURFACE ®nwacuaa+nc.ae.r�+�.->_a.I.va•n•'a''^^%ave""''aaa°'T°°'^r^""'"`e:rs.+sa.a•.�sa1 EIEXPLOSIVE FROM TO DEPTH OF w FT BELOW SURFACE WELL IDs: I ❑+ EXPLOSIVES FROM s..arnm TO GROUT SPECIFICATIONS --i" MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS HOSE PIPE V ❑ II COMMENTS See blast ° ry 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS work will be done in accordance with San Joaquin County Ordinances,Rules and I hereby certify that I have prepared this application and that the Regulations,and all applicable California laws. y prgact Scientist IARCADIS U.S..Ina Signed _� - D "`�'�= Title/Compan Date September 5,2014 Print Name Ju .Munn DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE.SITE ADDRESS - VE T Cxdu TE>7 WORK PLAN DATED ,1 DATE ISSUED 9-/T f LI AREA 14 APPLICATION ACCEPTED BY J 7 OH'K rt'rn FINAL INSPECTION BY DATE GROUT INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# So 2 $130x5 7 6 Izg ClvurvrN' 540-`4 SR# 705S7 3503 bio 390 3500 Ro-58 PR# 2900 E 29 - _ WC a�_WAIVER 1�. C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT �ENCROACHMENW DOPER-APP �`- EHD 29-01 /24/14