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s • 0 . � ylVrjfTG �0 4U��.:ca SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV �d•./Fba b Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:wwwsiaov.org/eh 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 437Eest Miner Ave Cross Street e2lifdN2 sheet City/State Sloalm.CA Zip 95202 APN 139-24-017 Property Owner Chevron Environmental Manegamenl Address 61118ollinger Canyon Rd,Room3652 City/State San Remon,CA Zip 94583 Phone 92654&2349 C-57Contractor Cascade Dulling LLC Address 30000uluth S8ee1 City/Slate West Sac,CA Lie 938110 Phone 91663&1169 Consultant/Sub Cntr ARCADISU.S.,Inc. Address 101 Creektide Ridge Cma,Suite 200 City/State Rosevl6e,CA LIe Phone 918.786-0320 Billable Party ARCADIS U.S.,Inc Address Mood" City/Stale Zip Phone GIS Coordinates:X37.951.7G v LLZ ?cc%(9 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDS ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONrrCRING ❑HOLLOW STEM DIA.OF BOREHOLE_ MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —0 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 ❑HOSE ❑PIPE _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _[3 INJECTION e.e.Nr soeme.ozonel❑HAND AUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Ole: 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) 56 #OFWELL(S)TOBE DESTROYED ISVP-tA/B,-2N8,-3A1e,-4A/B,.SA/6..6PlB,lA/B,sAIB] + OVER-BORE DIAMETER OF a INCHES TO DEPTH OF p FT WELLIDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS aw »^i ❑EXPLOSIVES FROM so.mm e.. To +� FT BELOW SURFACE TREMIE TYPE TO BE USED:Lj AUGERS UHOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS Sea blast plan fori ivi u Iwellex I v eryIs.Shallow soll Vaco,fSVPI wells to be hand amered and deep SVP wells will be over-dIII,d 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable Californiaalrlaws. Signed _XIAZl1_`�, /I CL(i{Y--.(.-- Title/Company Project Scientist/ARCADIS U.S.,Inc. Print Name JuliA.Munn Dale September5,2014 DEPARTMENT USE ONLY 1 SITE MAP IN UNIT IV FILE-SITE 'ADDRESS 4/37 <'• 011A106VES S7WC7ZX WORK PLAN DATED SEP TEfy'1 BFK ♦ t Z10Z1 yoy �1 APPLICATION ACCEPTED BY J• 1 OOK It A DATE ISSUED I AREA /G9 q GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE CO M M E NTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE 4 g REQUEST PR# �J O'j� 8113300xs 728o\ I ZV �[JLtrV7L'-Q /'�O./[( SR# 705-5'2JJ O TjU 3�U 8 00 PR# 2900 C57 7i WC �i WAIVER all F1 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC A.109EHD 29-017/24/14 WELL PERMIT APP