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iuffTt4. \ SAN JOAQUIN COUNTY C 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N' < <br /> `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.org/eh UNIT IV <br /> 4 '%KOy <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 437 East Miner Ave Cross Street California street CiWStale SlocIdOM.CA Zip 9s202 APN 139-24-017 <br /> Property <br /> Owner Chevron Environmental Management Address 6111 Bollinger Canyon Rd,Room 3652 City/state San Ramon,CA Zip 94593 phone 925-64}2349 <br /> C-57 Contractor Cascade Drilling LLC Address 3000 Duluth Street City/State Wesl S8C,CA Lic 938110 Phone 916-538-1169 <br /> Consultant/Sub Cntr ARCADISU.S.,Inc. Address 101Creekdde Rldge Coud,Suh.2Go City/State Rosevllle,GA Lic Phone 916-786.0320 <br /> Billable Party ARCADISU.S.,Inc Address Asebove City/State Zip Phone <br /> GIS Coordinates:X 37.95474 Y--:/2/,?4...,0% <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 WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor/Water O HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: D STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS O HOSE D PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION T a Ar Soame.Ozonal❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING D No D Yes:Casing Dia: Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS 8.BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) <br /> 56 #OF WELL(S)TO BE DESTROYED ISVP-INB,-2AIB;3AI8,<A/B,-saa,-6wB,aAIB,-B/JB] 0 OVERBORE DIAMETER OF 8 INCHES TO DEPTH OF—WFT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS xen:..+m [D EXPLOSIVES FROM s..am m.. To '+saH FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Lj AUGERS LJHOSE CIPIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS See blast glao for indlMdual - exoloslyes '---- Vaoor SVPI wells mw-hand. red and decd SVP wells win be over-drilled <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 <br /> all applicable California�s � laws. <br /> Signed /11A Zf Imo/+ I/ LL(i{�-�( Title/Company Project Sclentlst/ARCADIS U.S.,Inc <br /> Print Name Ju Munn Date September 5,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS A137 C ►t9/e/E2 /4UEr S17-&—CT0') <br /> WORK PLAN DATED se-r6fnJBl H z0/4/ <br /> APPLICATION ACCEPTED BY J• 7 o►}K k M DATE ISSUED OT^/fJ^f 1( AREA /(r <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M E NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID If FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> b REQUEST PR# <br /> (J O $130 XS 7 C� (Z CJ &;-UA/TZg�P 5-/O-"( SR# 705-5'? <br /> 3 O 3O 30(U S 00 <br /> PR# <br /> L2900) <br /> C57 WC -_;i WAIVER N./12 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC Alp <br /> EHD 2"1 /24/14 WELL PERMIT APP <br />