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FILE COPY oA4`'ln• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP a < 'F. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:.www.siaov.orq/ehd UNIT IV rtfFoa WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 34701 S.Welty Road Cross Street Highway 33 City/Stale Vernalis Zip 95385 APN 255-180-15 Property Owner Kamail Sandhu Address 3972 W Durham Ferry Road City/Stale Tracy Zip 95304 Phone (209)612-1127 C-57 Contractor Penecore Drilling Address 1238 Alice Street,Suite A City/State Woodland Lic 906899 Phone (530)661-3500 Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City/State Oakland Lic N/A Phone (510).466-7148 Billable Party SAIC(see above) Address City/Stale Zip Phone GIS Coordinates:X -121"29056 y 37.63480 V e CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT GEOPROB YDROPUNCH,HAND-AUGER,OTHER) ©SOIL BORING IDs SB-7 SB-8&SB-9 _ ❑WELL IDS ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA_OF BOREHOLE 3.25" ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE g]PIPE 3 ®SOIL BORING ©PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e.Air Soaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Ola COMMENTS:Fieldwork is on behalf of Chevron Site name Ahern Road Vemalis fSJCEHD reference address-35500 Welty Road) NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF W ELLS)TO BE DESTROYED - ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF - FT WELL IDs: [IPRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑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,and all applicable Calif a laws. Signed �� Title/Company Project Geologist/SAIC Print Name Sean Gehike Date 11/14/2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORKPLAN DATED C'c`w►�E�C 8 U frMumcn APPLICATION ACCEPTED BY l�Ku DA °i - EA_Z GROUT INSPECTION BY - FINAL INSPECTION BY 4 !+ TE.12LII=%2 DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# S 125x / c)C) C'T r2 l l-i - 2 SR# r. .. RO# ago 3 3 �7 3500 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