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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 />GROUT SPECIFICATIONS neat cement (95%)/bentonite (5%)
<br />TREMIE TYPE TO BE USED ID AUGERS EJ HOSE El PIPE
<br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY(
<br />OVER-BORE DIAMETER of 10 inches to depth of s20 feet
<br />EKI PRESSURE GROUT To depth of 50 feet below surface
<br />0 EXPLOSIVES From to feet below surface
<br />MUSHROOM CAP rj 3 feet below surface or feet below surface if >3 feet
<br />Title/Company Environmental Scientist, Arcadis
<br />Date
<br />PARTMENT USE ONLY
<br />Signed
<br />Print Name Davis
<br />Application Accepted By:
<br />Grout Inspection By/Dates:
<br />Destruction Inspection By/Dates:
<br />Facility/Site Information
<br />Date Issued:
<br />SAN JOAQUIN
<br />COUNTY
<br />''veo
<br />Environmental HealtIkApASSIEncnt
<br />%,vatf 10/8
<br />410vr'IL
<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 575W. Grant Line Road
<br />
<br />City/State/Zip Tracy, California 95376 Phone
<br /> N/A
<br />Cross Street N. Tracy Boulevard
<br /> APN
<br />
<br />21449003
<br />Property Owner* Chevron
<br />
<br />Phone N/A
<br />Address 120 S. 23rd Street City/State/Zip Richmond, California 94804
<br />Address 145 State College
<br />C-57 Contractor Cascade Drilling
<br />City/State/Zip Brea, California 92821
<br />License# 938110 Phone 707-639-7709
<br />Consultant/Sub-Contractor Arcadis License# N/A 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 />TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br />MONITORING 0 HOLLOW STEM BORING DEPTH Q BOLTED TRAFFIC BOX 0 STOVE PIPE
<br />EXTRACTION (Vapor/Water) 0 HAMMER/DRIVEN DIA. OF BOREHOLE CI MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA
<br />SOIL VAPOR PROBE 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC CI OTHER
<br />SOIL BORING DI PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes 0 No Boring Dia: Casing Dia: Casing Depth:
<br />INJECTION (Air Sparge, Ozonel CI HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: CI AUGERS El HOSE CI PIPE
<br />OTHER 0 OTHER: GROUT SEAL PUMPED? El Yes 0 No (Note: Maximum Freefall Depth is 30 Ft)
<br />WELL/ SOIL BORING IDs GROUT SPECIFICATIONS
<br />COMMENTS: Wells MW-1, MW-2, MW-3, MW-4, MW-6A, and MW-7 will be overdrilled due to insufficient annular seal. Wells MW-5 and MW-6B will be pressure grouted.
<br />ereby ertify that I a 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 />FA Name FA Address 575 (7,,,,,,,Is _l _,, 0 F A# a 0 1 c._c1 PR#
<br />FA PE 2-ct C.,6) WP Reviewed By
<br />I-- X Work Plan Date
<br />0 C-57 E6-57 Authorization for Other to Sign Permit 0-Workers Comp 0 Worker's Comp Waiver CI Encroachment Permit 0 Access Agreement 12 Lead Agency Approval E6FR
<br />COMMENTS/CONDITIONS: A%1 ...yetis 5-1\ lya.. c...it..4--_-9,-;1.-. 2-,-....c ,A-.6,....- ;., 46,2, 4„,,,..,,,,....t-,,-,...,,...,0.....A.,, 5AA .......... Q ,,,ak ,....)0442.,r- Ckiif lpa-a4 - rcM n,..."-Lare- 5.e...Ne.vv.4---..e.64 t.„,,....t I .1.4_ c.a...e+,....-cd , G.-4,,,,,...,
<br />-1.,.ii ci ispu_See(
<br />WP TYPE Pk SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT* INVOICE#
<br />Permit ?Iv i 3i 3 $152x 5— t --7 VO ic"-(9 Z-3 1--)‹. '110 j11 4—) POO '391 0
<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
<br />P vi 0 3 5-23 2-049 111 sp-vor000s—
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