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SAN 10AQUIN Environmental Health Department CC)UNTY SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 2700 W.Washington Street City/State/Zip Stockton, CA Phone Cross Street Navy F)rive APN 145-030-12 Property Owner' Buckeye Partners, LP - Jeff Brudereck Phone (610) 904-4019 Address Five TEK Park/9999 Hamilton Blvd. City/State/Zip Breinigsville, PA 18031 C-57 Contractor Cascade Drilling License# 938110 Phone (530) 662-2829 Address 2083 E. Main Street City/State/Zip Woodland,CA 95776 • Consultant/Sub-Contractor Stantec Consulting Services License# Phone (916) 472-3915 Address 3875 Atherton Road City/State/Zip Rocklin, CA 95765 CONSTRUCTION WORK TO BE PERFORMED:`Note: Offsite 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: 0/97EEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: ❑ INJECTION(Air Soarae.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE T E USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum 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 31 ❑OVER-BORE DIAMETER of inches to depth of feet WELL IDs S-32 thru OS-39,0S-41,10S-53 thru OS-57,OS-9B thru OS-16B N PRESSURE GROUT To depth of 37 feet below surface GROUT SPECIFICATIONS bleat Cement ❑EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: All wells will be pressure grouted. This permit application is a change of scope to permit WP0037548. ereb c r i that I am authorized to complete this application and that the work will be done in accordance with 7:�an Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Title/Company Sr. Project Manager/ Stantec Print Name Ef7an Schreiner Date 02/22/18 DEPARTMENT USE ONLY Application Accepted By: Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Information FA Name A Address FA# PR# FA PE WP Reviewed By Work Plan Date ❑C-57 ❑C-57 Authorization for Other to Sig ennit ❑Workers Comp ❑Worker's Comp Waiver ❑Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: WP TYPE PE Sc FEE INFO AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit $152 x 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application