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RECEIVED 3 2012 SAN JOAQUIN COUNTY 1.X ENVIRONMENTAL HEALTH DEPARTMENT LOP SITE MITIGATION VIRONMENTALHE�� Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV T P�§09) 468-3147 Fax: (209) 468-3433 Web:www.sogov.org/ehd O'R WELL & BORING PERMIT APPLICATION �\�oNM`�1S�PJOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION EN QIP 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/State Vernalis Zip 95385 APN 255-180-15 Property Owner Karnail Sandhu Address 3972 W Durham Ferry Road City/State 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)661-3600 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/State Zip Phone GIS Coordinates:X -121.29056 Y 37.63480 CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT EOPROB YDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs SB-4 B-5.&SB-6 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE R1 PIPE 3 2 SOIL BORING 2 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ®No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air sparge.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 Dia: COMMENTS:Fieldwork is on behalf of Chevron. Site name: Ahern Road-Vernalis(SJCEHD 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: ❑PRESSURE 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 L?