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i �~y oe°`'tn- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP "; ` SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV - `;�i;=oa�:P• 7 elephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s]ctov.org/ehd 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 cf 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 Karnail 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 Cily/S tale Woodland LIc . 906899 Phone (530)661-3500 Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City/Slate Oakland Lir. N/A Phone (510)466-714a j Billable Party SAIC(see above) Address Cily/Slate Zip Phone , I GIS Coordinates:X -121.29056 y 37.63480 U I CONSTRUCTION WORK TO BE PERFORMED: M NEW WELUBORING(CPT GEOPROB YDROPUNCH,HAND-AUGER,OTHER) El SOIL BORING IDs SB-7 SB-8&SB-9 ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS T� _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER(ORIVEN CASING THICKNESS N/A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER —C)SOIL VAPOR PROBESurface ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE IKI PIPE 3 ®SOIL BORING ©PUSH POINT(GP/CPT) GROUT SEAL PUMPED:E)Yes l]No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION f.e.ar Suatie.oz-1❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feel bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dla COMMENTS:Fieldwods is on behalf of Chevron Site name: Ahern Road-Vernalis(SJCEHD reference address=.35500 Welly 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 Fr BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED O AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 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 Califa laws. Signed Title/Company Project Geologist/SAIC Print Name Sean Gehlke Date 1 111 4/201 2 DEPARTMENT USE pONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 5 WCL 7 uI ►�U�� (/F2 �� 1 S WORK PLAN DATED APPLICATION ACCEPTED BY Ku P11 DATE ISSUED 2- 2'1? . AREA /69�9 GROUT INSPECTION BY' FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# �vS s125X Ci v()0 --- C't2 rl-1 - 2 SR# GG lG / O 37� RO# � -- 3500 PR# (2900) C-57 L-,"_ WC _ ✓ WAIVER fv-) 1� C-51 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC EHD 29-01 5/09/12 - - WELL PERMIT APP