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qD'N SAN JOAQUIN COUNTY (C on, (` to ` y ENVIRONMENTAL HEALTH DEPARTMENT Lo L 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.siUNIT IV clov.orq/eh FO� 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. .,( vj Site Location 437 East Miner Ave Cross Street Caliromis Street City/State Slockton.CA Zip 95202 APN GTS D Property Owner Chevron Environmental Managemanl Address 6111 Bollinger Canyon Rd,Room 3652 City/Stale Sen RamogCA Zip W563 Phone 925-543-2349 C-57 Contractor cascade Drilling LLC Address 3000 Ddulh Street City/Stale West Sac,CA LIC 936110 Phone 918539-1169 COnsultant/Sub Cntr ARCADISU.S.,Inc. Address 101 Cr.Wde Ridge Court,SUile 200 City/Stale Roseville,CA LIC Phone 916-7855320 Billable Party A14AAD1SJS. Ini Address �L- / Bf(YC City/State Zip Phone GIS Coordinates:X 2 R 4n Y -121- CONSTRUCTION 1�1-CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,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: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 O HOSE O PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e Ar Soame.0zone1❑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) 23 #OFWELL(S)TOBE DESTROYED ❑OVER-BORE DIAMETER OF NCHES TO DEPTH OF FT WELLIDS: Ua,ua,Uo.u.ia,uis,U.n,u.l4,wts,wa,u.v,u22.u.2yua,uas,sc.ua¢,sPa=,Nnaammllle ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS s..,..m.M [D EXPLOSIVES FROM ...... TO FT BELOW SURFACE TREMIE TYPE TO BE USED:Lj AUGERS Lj HOSE PIPE C]MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS see blast plan for Individual well e Intervals. g 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. /\ Signed yAt T� �Wu*—(^- Title/Company ProJaa SdanIIst/ARCADIS U.S.,Inc. Print Name Jull D.Munn Date September 5,2014 ' /DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS "7 -V C. AIA ce 4u-- T7emPaK) WORK PLAN DATED SE P7z-m 261 r< _ APPLICATION ACCEPTED BY _I !joA-kuWl DATE ISSUED y5-I y AREA G GROUT INSPECTION BY FINAL INSPECTION BY DATE 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 FIR 3501 $130X23 8o IL8 688 00u&rX2 �T- lwu SR# �o Spo 350 390 (300 PR# (2Boo C-57 L/ WC WAIVER NA C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC Ir' EHO 29-01 7/24/14 WELL PERMIT APP