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S A N sd 0 A Q U IN Environmental Health Department <br /> COUNTY <br /> 4�� <br /> _, -,a` Greatness grows her <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 descritobd. <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 3003 Navy Drive City/State/Zip Stockton, CA 95206 Phone <br /> Cross Street WW-Washington Street APN 145-030-1 1 <br /> Property Owner" Tesoro Logistics - Darrell Fah Phone (562) 495-6876 <br /> Address 400 Oceangate, Suite 600 City/State/Zip Long Beach, CA 90802 <br /> C-57 Contractor Cascade Drilling License# 938116 Phone (530) 662-2829 <br /> Address 2083 E. Main Street City/State/Zip Woodland, CA 95776 <br /> Consultant/Sub-Contractor Stantec Consulting Services License# Phone (916) 472-3915 <br /> Address 3875 Atherton Road City/State/Zip—Rocklin, CA 95765 <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Borings/Wells Require Access Agreements or EncroachmertTPe its'E IV ED f <br /> TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPFEB 2 6 2018 <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVCrr��y OTHER )I H� <br /> ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Bo ng Dia: Casing Di►l1,V i IZ 11.t <br /> ❑ INJECTION(Air Soarce.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSEtPVFk RT n I E N I <br /> ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes❑No (Note:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDS GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #WELLS TO BE DESTROYED 14 /❑OVER-BORE DIAMETER of inches to depth of feet <br /> WELL IDS OS-18 thru OS-31 ®PRESSURE GROUT To depth of 37 feet below surface <br /> GROUT SPECIFICATIONS Neat Cement /' El 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 /> All wells will be pressure grouted. This perniii application is a change of scope to Permit WP0037547. <br /> 1 hereby certify thitt I am authorized to;complete this application and that the work will be done in accordance with <br /> S J quin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed A Title/Company Sr. Project Manager/ Stantec <br /> Print Name Dari chreiner Z Date 02/22/18 <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 /> E <br /> FA PE WP Reviewed By Work Plan Date <br /> ❑C-57 ❑C-57 Authorizatio or Other to Sign Permit ❑Worker's Comp ❑Worker's 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 />