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PpUIIy 7 J <br /> SAN JOAQUIN COUNTY <br /> -=rIIE�"'•.OG <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> P' Telephone 209 468-3147 Fax: 209 468-3433 Web:www.sigov.ora/ehd UNIT IV <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. R04 3 <br /> Site Location 7647 Pacific Avenue Cross Street Rivara Road City/State Stockton,CA Zip 95207 APN 077-480-14 <br /> Property Phillips 66 <br /> Owner p Address 1380 San Pablo Ave. City/State Reno,CA Zip 94572 Phone 510.245.4423 <br /> C-57 Contractor Gregg Drilling&Testing,INC Address 950 Howe Rd. City/State Martinez,CA Lic 485164 Phone 925-313-5800 <br /> Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave.,Suite 201B City/State Modesto,CA Lic 95351 Phone 209.579.221 <br /> Billable Party Cardno ATC for Phillips 66 Address 1117 Lone Palm Ave.,Suite 201B City/State Modesto,CA Zip 95351 Phone 209.579.221 <br /> GIS Coordinates:X 38.01921 Y--1 21.32418 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> El NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs MW-23 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i LI MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 8 In ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch.40 TYPE OF CASING: ❑STEEL [D PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS El HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i e Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement cirout <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 55-60 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING 21 No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Well installed as described in Cardno' "Work Plan for Additional SQ0 and Groundwater Assessment"dat d August 12 2014 <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 all applicabl California laws. <br /> Signed _Title/Company Cardno ATC <br /> Print Name Je ne Homsey Date 12/17/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS aolF I ✓�eK�� <br /> WORK PLAN DATED u( S T/ <br /> APPLICATION ACCEPTED BY J-� DATEISSUED AREA)6G2 <br /> GROUT INSPECTION BY FINAL INSPECTION BY 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 RO# INVOICE <br /> REQUEST I PR# <br /> SR# /23 � <br /> 3 5�3 3`[o (3o0 <br /> PR# <br /> (2900 <br /> C-57 1/ WC _WAIVER—N `� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> EHD 29-01 5109112 WPI 1 PFPMIT APP <br />