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• SAN JOAQUIN COUNTY 6 O ` I V I JA f ENVIRONMENTAL HEALTH DEPARTMENT -Lop L 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.siaov.oru/eh WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION,JUN 1 2�1Z NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��T�' HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is mad£py{�r Q y Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 0A%tpEFtm1TI S Site Location 3003 Navy Drive Cross Street W.Washington Sl. City/State Stockton,CA Zip 95206 APN ��5, G 2U.-080 Property Owner Tesoro Companies Inc. Address 3450 South 344th Way City/State Auburn,WA Zip 98001 Phone 210-283-2000 C•57 Contractor WDC Exp&Wells Address 9580 Co Road 93D City/State Zamora,CA Lic 283326 phone 530-G61-2010 Consultant/Sub Cntr Stantec Address 3017 Kilgore Rd,Ste 100 City/Stale Rancho Corde�a,CA phone 916-861-0400 Billable Party Stantec Address 3017 Kilgore Rd,Ste 100 City/State Rancho Cord,CA 95670 Phone 916-861-0400 GIS Coordinates:X Y CONSTRUCTION WORK I U BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs TS/M..-.- El OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _[N MONITORING El HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4 W _I]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch 80 TYPE OF CASING: ❑STEEL 0 PVC ❑ OTHER _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 80 TREMIE TYPE TO BE USED: [AUGERS I]HOSE ❑PIPE W _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —El INJECTION I.e.AirSoameOzwel❑HAND AUGER GROUT SPECIFICATIONS _O OTHER: ❑OTHER: APPROX.BORING DEPTH 95 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS r-67 DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHEGK ALL THAT APPLY Varies by well _#OF WELLS)TO BE DESTROYED OVER-BORE DIAMETER OF 0 INCHES TO DEPTH OF 17 to 13� WELL IDs: TS/MW-1 D to TS/MW-0D,OS-1 to OS-17,OS-1B to OS-8B ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUTS ]CATIONS Neat Cement ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:[K AUGERS ❑ HOSE El PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 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, all ap licable Cal' Ora laws. / ,,L Signed //�� P/.(fi/n-t Title/Company M4rlag !-ml SC.A!o i1 b CO �O yl / Print Name _LIQ M l/ 1.1 G L In P !' Dal - DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS ///9Vy 1) Wp c 141ur-Td4J WORK PLAN DATED 51 Z01 Z APPLICATION ACCEPTED BY J.NoAR.til DATE GROUT INSPECTION BY FINAL INSPECTION BY 7F� 2' DESTRUCTION INSPECTION BY DATE COMM ENTSICON DITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 240;2. $125x- cO 3750 34l3` 44< SR /b 30 5 RO (DSO 1 37S 1 PR# 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP I