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SAN 10A0UIN Environmental Health Department NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7597 For INSPECTIONS 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 San Joaquin County Well Standards. 14821 West Grant Line Road Job Address Cross Street West Byron Road Property Owner Gary F. Dobler Address 276 W. 20th Street C-57 Contractor Penecore Drilling citylstace/Zip Tracy, CA, 95376 aPt� 209-190-06 Phone N/A Phone 209-$36-3316 City/Ste teJZip Tracy, CA, 95376 License# 906899 Phone Address 220 N. East Street State/Zip Woodland,CA, 95776 Consultant/Sub•Contractor Arcadis US, Inc. License# NJA Phone Address 735 Tank Farm Road Suite 150 City/State/Zip San Luis Obispo, CA, 93401 COPJSTRUCTION WORK TO BE PERFORPUIED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER ® MONITORING ❑ ❑ EXTRACTION (Vapor/Water) ❑ :1 SOILVAPORPROBE ❑ (� SOILBORING —❑ :1 INJECTION (Arr sparaa, ozona) `1 OTHER ❑ 1NELLIEOILBORING IDs SB -1 through SB -E 530.661.3600 805.459.2391 INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS HOLLOU'! STEM BORING DEPTH 5.0 ❑BOLTED TRAFFIC BOX ❑STOVE PIPE HAMMERIDRIVEN DIA. OF BOREHOLE —3in ❑ MULTIPLE CASINGS ❑ MULTI•LEVEL WELL CASING DIA MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL El PVC [I OTHER PUSH POINT (GPI CPT) CONDUCTOR CASING El Yes ❑ No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS El HOSE El PIPE OTHER: GROUT SEAL PUMPED? ❑ Yes ❑ No (Note: Maximum Freefall Depth is 30 Fit GROUT SPECIFICATIONS Neat Cement grout DESTRUCTION WORK TO BE PERFORMED: #WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USE _DESTRUCTION METHDD: (CHECK ALL THAT APPLYt ❑ OVER -BORE DIAMETER of inches to depth of �„ feet ❑ PRESSURE GROUT To depth of. feet below surface ❑ EXPLOSIVES From to feet below surface MUSHROOM CAP El 3 feet below surface or feet belay surface if >3 feet MMENTS:Six soil borings are anticipated for this scope of work. Additional Soil borings may be required and completed during the field pending field conditions.All borings will be hand angered to TD and subsequently abandoned using neat cement. Signed Print Name hereby certify that 1 am authorized to complete this application and that the work will be done in accordance San Joaquin County Ordinance Codes and Standards, and all otI)er applieabte California t f,1 , !_ Title/Company aws. _(tt? Pro1 1c; to Mana er, Arcadis US., Inc. Christine Perez �g Date 02J24122 Application Accepted By: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facility/Site Information FA Name Chevro JEFFREY WONG Date Issued: 3/15>f2022 Station FA Address 14821 Grant Line F'°� FA0013993 PR# PR0518596 FA PE 2960 WP Reviewed By JW Work Plan Date 8!24/2021 EIC -57 )Q C-57 Authorization for Other to Sign Permit ❑ Worker's Comp ❑ Worker's Comp Waiver ❑ Encroachment Permit ❑ Access Agreement �Q Lead Agency Approval ;Q MFR COMMENTSICONDITIONS: Submit report/analytical results to EHD per SJC Well Standards 13.7.2 WP TYPE PE SC FEE INFO AMT REMITTED CHECK## RECV'D BY DATE WELL PERMIT# INVOICE# Permit SOC 313 1$152 x 3 456 CC JW 3/15/22 WP0043076 CONFIRMATION #140549480 SR0085006 1868 E. Hazelton Avenue � Stockton, California 95205 1 `i 209 468-34201 F 209 4641111,0138 � vvww.sjgov.org/ehd [HD 29-01 06-28-21 Site Mitigation Well Permit Application n Trac Pum