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SAN 10AQUIN Environmental Health Department <br /> COUN l Y <br /> Greatness grows here. <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 desc� ed. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaq i County Well Standards. <br /> Job Address 3003 Navy Drive City/State/zip Stockton CA 9 206 Phone <br /> Cross Street W-Washington Street APN 145-030-11 <br /> Property Owner' Tesoro Lo istics - Darrell Fah Phone (562) 495-6876 <br /> Address 400 Oceangate, Suite 600 City/State/Zip Lon a 90802 <br /> C-57 Contractor Cascade Drilling License# 93 Phone (530) 662-2829 <br /> Address 2083 E. Main Street City/State/Zip WoVdlak, CA 95776 <br /> ConsultanUSub-Contractor Stantec Consulting Services License# Phone (916) 472-3915 <br /> Address 3875 Atherton Road City/State/Zip o in CA 95765 <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Re ess Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATION <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑` TED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑ LTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYP OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING Y ❑No Bon Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Soarae.Ozone) Cl HAND AUGER GROUT SEAL DEPTH THE IE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? Yes ❑No e:Maximum Freefall Depth is 30 Ft) <br /> WELL]SOIL BORING IDs GROUT SPECIF,IC 0 <br /> DESTRUCTION WORK TO BE PERFORMED: /A N DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 14 L/ �1 N OVER-BORE DIAMETER of 8 inches to depth of 37 feet <br /> WELL IDs CIS-18 thru OS-31 ®PRESSURE GROUT To depth of 37 feet below surface <br /> GROUT SPECIFICATIONS Neat Cernent ❑EXPLOSIVES From to feet below surface <br /> TREMIE TYPE TO BE USED [:]AUGERS ❑HOSE ®PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: <br /> Wells will be over-bored unless site limitations prohibit access with augers. <br /> I hereby certify that I am authorized complete this application and that the work will be done in accordance with <br /> Z'- <br /> n Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed d/ Title/Company Sr. Project Manager/ Stantec <br /> Print Name Dan Schreiner Date 10/11/17 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit /Site Information <br /> FA Name FA Address FA# PR# <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />