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0 0 coo Fly <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �I SITE MITIGATION <br /> — 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> Telephone:(209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh <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,Deveop erTt 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 Calawnla sveet City/State sbcMon,CA Zip 95202 APN 139-24-009 <br /> Property <br /> Owner Chevron Envimnmental Management Address 6111 Bollinger Canyon Rd,Room 3652 City/State San R..,CA Zip 94583 Phone 9255432349 <br /> C-57 Contractor Cascade Dulling LLC Address 3000 Duluth Street Cltylstale West Sac,CA LIC 938110 Phone 918.838-1169 <br /> Consultant/Sub Cntr ARCADISU.S.,lnc. Address 101 Creekside Ridge Coun,Suite 200 City/Stale Roseville,CA LIC Phone 916786-0320 <br /> Billable Partys Address ,Aft`(- City/State Zip Phone <br /> GIS Coordinates:NOW72.c3 Y -12/,zeg83 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MCWTORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS❑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 /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION((.a Air6Dams.Leone)0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: 0 OTHER: APPROX,BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 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 /> 3 #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: u-11.u-12.u1s ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS wme.mmt E EXPLOSIVES FROM anal.oi TO--- FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS LJHOSE LJPIPE E] MUSHROOM CAP AT(>3 Fr) FT BELOW SURFACE <br /> COMMENTS S..btast plan forindl'dualvre ez olives ine 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 CaliforniaClllaws. <br /> Signed �AtWI 7. 7>, I/ [u/1��' Title/Company ProjectScientist/ARCADIS U.S.,Inc. <br /> Print Name AI D.Munn Date September5,2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Y7 F 01,PEQ '464' <br /> WORK PLAN DATED20 11 _ <br /> APPLICATION ACCEPTED BY .t `'1619•ICun) DATE ISSUED AREA 1G <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> CO M M E NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 35 UZ $130x T>G o �&UVgrxk -IG SR# 70}5 <br /> 3R°a <br /> PR# <br /> 2900 <br /> C-57 ./ WC WAIVER�i� C57 LETTER OF AUTHORIZATION TO SIGN PERMIT !� ENCROACHMENT DOC /y+�l <br /> EH 29-029-01 7 4/14 WELL PERMIT APP <br />