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C 00 PN�-' <br /> ifVfrTC -1,5— .oG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www,sigov.org/eh UNIT IV <br /> 4 /FOJ' <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 Calirbmia street City/State Stockton,CA Zip 95202 APN 139-24-017 <br /> Property <br /> Owner Chevron Environmental Management Address 61118ollin9er Canyon Rd,Room3652 City/State San Ramon,CA Zip 94583 Phone 925-543-2349 <br /> C-57 Contractor Cascade Drilling LLC Address 3000 DulunnStreet City/State West Sac,CA Ui 938110 Phone 916.638-1169 <br /> Consultant/Sub Cntr ARCADISU.S.,Inc. Address 101 Creehside Ridge Cost,Suite 200 City/State Roseville,CA LJC Phone 916.7B"320 <br /> Billable Party ARCADISU.S.,lnc Address Ae BboveO City/State Zip Phone <br /> GIS Coordinates:X3'�•9S47G Y -12f,?r•5-SG8 <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 0 HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _O EXTRACTION:Vapurl Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _❑SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION 6a Alr Soam..Ozonel 0 HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER: ❑OTHER: APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX OR C STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 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 /> 56 #OF WELL(S)TO BE DESTROYED ISVP-1AIB,-2NB,-3A/B,APl9;5AIB,-649,--/AIB,-BAIB] 0 OVER-BORE DIAMETER OF a INCHES TO DEPTH OF 20 FT <br /> WELL IDs: es1 E3PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Naacerem [D EXPLOSIVES FROM so.el.n m.. TO aumw FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Ll AUGERS UHOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS See bl,5t plan for indivive.Intees.ShMov,soll Vapor SVPI wells V win I <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 1 IA 1, '�, /1 CL(/( Title/Company Pro)ect Scientist/ARCADIS U.S.,Inc. <br /> Print Name JAWb Munn Date September 5,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE <br /> '' 11 <br /> ADDRESS /4137 C• NIA16e V S� <br /> r OZA) <br /> .JGIo <br /> WORK PLAN DATED '�Ei✓IBEK JJ ZOyN <br /> APPLICATION ACCEPTED BY J y OIK U AA DATE ISSUED AREA /G <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 SERVICST E RO PR## <br /> REQUEINVOICE <br /> �y <br /> 225O � S 113300XS 7 6 12 8 &UrtT(L�Q �—/O-l[( SR# 705-5 ? <br /> ; <br /> JJV 3 J70 3S0 RO# <br /> 3500 <br /> PR# <br /> z900 <br /> C-57 f i WC iLWAIVER all I1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC Nft <br /> EMD 29-017/24/14 WELL PERMIT APP <br />