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COPY <br /> SAN JOAQUIN COUNTY <br /> �N2 ?� ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> •`�, � I� �'• 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 /> sC%Far% P ( ) ( ) <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 C.Street Celifomia Street City/State Stockton,CA Zip 95202 APN 0 Vj <br /> Property <br /> Owner Chevron Environmental Management Address 6111 Bollinger Canyon Rd,Room 3652 City/State $9n Ra—.CA Zip M583 Phone 926543-2349 <br /> C-57Contractor Cascade Drilling LLC Address 30011 DUu0 Street City/State West Seq CA Lie 938110 Phone 918-638-1169 <br /> Consultant/Sub Cntr ARCADIS U.S.,Inc. Address 101 CreeWd.Ridge Coud,Suit.200 City/Stale Roseville,CA Uc Phone 916786-0320 <br /> Billable Party a2fiAD16 JS. lhl'— Address City/Stale Zip Phone <br /> GIS Coordinates:X 2!nr. �p Y -/21, �. 14 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑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 /> _0 INJECTION fl..Air seams.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Ola: <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 /> 23 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> 'WELLIDs: ua,w,ugu-m.ws.u.n.uu.u.m,ua.v.xt,azs.ua.vm,ws.sys..vc,sysa vc,ne-z-mmrna ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS a-e=•^ L ❑' EXPLOSIVES FROM s..a..em, TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Lj AUGERS Lj HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS See blast Dien for individual well explosives intervals.' <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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/apD�plicable California laws. <br /> Signed /\tM, t `u/t,—( Title/Company Prclecl Sclengst/ARCADIS U.S.,Ine, <br /> Print Name Ju, .Munn Date September 5,2014 <br /> DEPARTMENT USE ONLY�� �.1 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS_ N 37 C. oyma6 4u-- S'rrr�aecric u <br /> WORK PLAN DATEDSE P1T�M <br /> APPLICATION ACCEPTED BY _l. DATE ISSUED y5"/N AREA 769V <br /> GROUT INSPECTION BY FINAL INSPECTION BY '1-. 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 SERVICE RR' INVOICE <br /> REQUEST PR# <br /> 3TO '1 $130X23 8a 12-8498 0ovf''2 `t- fwLl sR# 2o '5; <br /> 350 3 390 <br /> -RD o <br /> PR# <br /> (2900 <br /> C-57 V WC WAIVER IV 4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT P" ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />