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• /J�Vf /' FEn °�_ SAN JOAQUIN COUNTY -�- 1- ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION ,O'• ' Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.sigi D WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION JUN 1 2012 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby mad to San Joaquin County for a permit to construct and/or install the work described. This application is mad HEALTH Joaquin County Dev opment itle,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. ENatA9 A / PERMITIS nE3 Site Location 3003 Na Dri Cross Street W.Washing ton St o Property q City/State Stockton, Zip 95206 qpN Itis- 6 0 o "OLS Owner Tesoro Companies Inc. Address 3450 South 344th Wa C-57 Contractor WDC Exp&Wells Y Address 9580 Co Road 93D City/State Auburn,WA Zip 98001 Phone 210-283-2000 Zamora,CA 283326 Consultant/Sub Cntr Stantec City/State Lic Phone 530-681-2010 Address 3017 Kilgore Rd,Ste 100 Rancho Cord CA Billable PartStantec City/State 21Ca• Phone 916-861-0400 Party Address 3017 Kilgore Rd,Ste 100 City/State Rancho Cord CA 95670 GIS Coordlnates:X Phone 916-861-0400 Y CONSTRUCTION ORK TO BE PERFORMED: NEIN WELL/BORI G(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BO NG IDs ❑WELLI TS/M -5 � ❑oT IDs TYPE&#OF WELLIBORING INSTALLATON TYPE CONSTRUCTION SPECIFICATIONS _IN MONITORING EJ HOLLOW STEM DIA.OF BOREHOLE 6 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 4 _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch 80 _❑SOIL VAPOR PROBE TYPE OF CASING: ❑STEEL [/�PVC 11 OTHER ❑MUD ROTARY DEPTH OF GROUT SEAL 80 TREMIE TYPE TO BE USED: GAUGERS ❑HOSE _❑SOIL BORING ❑PUSH POINT(GPI CPT) - GROUT SEAL PUMPED: Yes ❑PIPE ❑ ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION('a A' S Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 95 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING IN No❑Yes:Casing Dia: CasingDepth: - P Boring Dia: N E: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTIO ORK TO BE PERFORMED: DESTRUCTION METHOD: cHECKALLTHATAPPLv Varies by well 3 OF WELLS) BE DESTROYED WELL IDs: TS/MW- D to TS/MW-4D,OS-1 to OS-17,OSAB to OS-86 OVER-BORE DIAMETER OF to 2 INCHES TO DEPTH OF 17 to 13� GROUTSPECIFICA,�IONS Neat Cement ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE TREMIE TYPE TO BE USED.®AUGERS ❑HOSE ®PIPE El EXPLOSIVES FROM TO FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 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,an %all applicable Cal' ornia laws. Signed /' n Title/Compan //IQ/l tiq l nC c- /' ..,t Print Name _S2 G2 N L/ I I (,� !' Y ��1 J L/I/d Y/ Eo C O �OVq l / Dated — DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS (i II WORK PLAN DATED 2 y APPLICATION ACCEPTED BY J. O ,c PC GROUT INSPECTION BY DATE A 6 DESTRUCTION INSPECTION BY FINAL INSPECTION BY DEDATE COMMENTS/CONDITIONS: F7 2 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK#2SERVICE RO#Q0a RECV'D BY DATE $125 x � REQUEST PR# INVOICE 99 'T7 4°w't,� 4"I-�2 SR 399O JhO�j C-57WC 2900) EHD 29-01 5/09/12WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP A.