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I S A N J Q A Q U I N Environmental Health Department -- —CDUN1 Y-- (� Greatness grows here RECENE10 SITE MITIGATION WELL & BORING PERMIT APPLICATION OCT 3 1 2017 For Wells and Borings Used for Contaminant Investigations and Remedlation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTF1 48 Hours Advance Notice Required For All 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. Job Address 3003 Navy Drive City/Statwzip Stockton,CA 95206 Phone Cross Street W-Washington Street APN 145-030-1 l Property Owner" Tesoro Logistics-Darrell Fah Phone (562)495-6876 Address 400 Oceangate,Suite 600 city/State/Zip Long Beach.CA 90802 C-57Contractor Cascade Drilling_ License# 938110 Phone (SiQ)662-2R29 Address 2083E Main Street City/State/Zlp Woodland,CA 95776 I Consultant(Sub•Contractor Stantec Consulting Services License# Phone (916)472-3915 Address 3875 Atherton Road Cny/StatelZip Rocklin,CA 95765 CONSTRUCTION WORK TO BE PERFORMED:'Note: Offstte Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING:❑STEEL❑PVC❑OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes❑No Boring Dis: Casing Did Casing Depth: ❑ INJECTION im Samao owot ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED:❑AUGERS❑HOSE❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes❑No (Note:Madmum Freefall Depth Is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED 14 ®OVER-BORE DIAMETER of 8 inches to depth of 3_feet WELL IDs OS-18 thru OS-31 ❑PRESSURE GROUT To depth of 37 feet below suriacts GROUT SPECIFICATIONS Neat Cement ❑EXPLOSIVES From _to feet below surface TREMIE TYPE TO BE USED [I AUGERS ❑HOSE®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feel COMMENTS: Wells will be over-bored unless site limitations prohibit access with augers. I herebyterjlfiii,that I am authorized to complete this application and that the work will be done in accordance with n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed_I __ Title/Company Sr.Project Manager/Stantec Print Name Dan Schreiner Dale DEPARTMENT USE ONLY Application Accepted By: Date Issued:�� b 7 Grout Inspection By/Dates: I ''eA Destruction Inspection By/Dates: vt Fa ill! /Site Informal n &Adgun tot. LOVtaY\ FA Name FA Address PR# S�� v v3 pr FA# lo o � vs `Z3� i�W/1 FA PE —6--J't WP Re ad By Work Plan Date 57 ❑C-57 Authorization for Other to Sign Per mll orkees Comp ❑Worker's Comp Waiver ❑Encroachment Permit (:]Access Agreement Lead Agency Approval R COMMENTS/CONDITIONS: a+ d-O, IWPWPEI PE SC I FEE INFO JAMT REMITTED1 CHECK# ECV'D BY DATE WELL PERM[T# INVOICE# Permit 5 $152 X 6 O j 7 Po '17 S '7 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-342 F 209 464-0138 1 www.sjcehd.com }Jp 29-01 0 1 � e Mae Permit Application Mitigation