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Signed <br />Print Name Cory Davis <br />SANJOAQUIN <br />COUNTY <br />Environmental Health Department <br />SITE MITIGATION 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 />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. <br />Job Address 575 W. Grant Line Road <br /> <br />City/State/Zip Tracy, California 95376 Phone <br /> N/A <br />Cross Street N. Tracy Boulevard APN 21449003 <br />Property Owner* Chevron Phone <br /> N/A <br />Address 145 State College City/State/Zip Brea, California 92821 <br /> <br />C-57 Contractor Cascade Drilling License# 938110 Phone 707-639-7709 <br />Address 120 S. 23rd Street City/State/Zip Richmond, California 94804 <br /> <br />Consultant/Sub-Contractor Arcadis <br />License# <br /> N/A <br />Phone 714-404-3064 <br />Address 320 Commerce, Suite 200 City/State/Zip Irvine, California 92602 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />HOLLOW STEM <br />HAMMER/DRIVEN <br />MUD ROTARY <br />PUSH POINT (GP/ CPT) <br />HAND AUGER <br />OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS TYPE OF WELUBORING <br />0 MONITORING <br />13 EXTRACTION (Vapor/Water) <br />ID SOIL VAPOR PROBE <br />El SOIL BORING <br />ID INJECTION (Air Spam, Ozone( <br />0 OTHER <br />WELL/ SOIL BORING IDs <br />BORING DEPTH <br /> El BOLTED TRAFFIC BOX 0 STOVE PIPE <br />DIA. OF BOREHOLE <br /> <br />ID MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br />CASING THICKNESS <br /> <br />TYPE OF CASING: El STEEL El PVC 0 OTHER <br />CONDUCTOR CASING El Yes 0 No Boring Dia: Casing Dia: Casing Depth: <br />GROUT SEAL DEPTH TREMIE TYPE TO BE USED: El AUGERS CI HOSE 1:1 PIPE <br />GROUT SEAL PUMPED? 1:1 Yes El No (Note: Maximum Freefall Depth is 30 Ft) <br />GROUT SPECIFICATIONS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY) DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED 8 <br />WELL IDs MW-1, MW-2, MW-3, MW-4, MW-5, MW-6A, MW-6B, MW-7 <br />El OVER-BORE <br />El PRESSURE GROUT <br />0 EXPLOSIVES <br />r4 MUSHROOM CAP <br />DIAMETER of 10 inches to depth of s20 feet <br />To depth of 50 feet below surface <br />From to feet below surface <br />0 3 feet below surface or feet below surface if >3 feet <br />GROUT SPECIFICATIONS neat cement (95%Vbentonite (5%) <br />TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE El PIPE <br />COMMENTS. ' Wells MW-1, MW-2, MW-3, MW-4, MW-6A, and MW-7 will be overdrilled due to insufficient annular seal. Wets MW-5 and MW-6B will be pressure grouted. <br />del ereby rtify that I authorized to complete this application and that the work will be done in accordance with <br /> San Joaquin ounty Ordinance Codes and Standards, and all other applicable California laws. <br />Title/Company Environmental Scientist, Arcadis <br />Date 1 2/7/15 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br /> <br />Date Issued: <br /> <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br /> <br />FA Name FA Address FN/ PR# <br />FA PE WP Reviewed By Work Plan Date <br />El C-57 ID C-57 Authorization for Other to Sign Permit 0 Woftees Comp 1:1 Worker's Comp waiver CI Encroachment Permit El Access Agreement 0 Lead Agency Approval El MFR <br />COMMENTS/CONDITIONS: <br />WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE* <br />Permit $152x <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application