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0RIG!NA ! 0P4`'ty- c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N` 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION . �q•. �;:P Telephone: (209)468-3147 Fax:(209) 468-3433 Web:www.si9ov.orgleh UNIT IV <<F OR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Standards of the San Joaquin County Environmental Health Department. Site Location 666 W Weber Ave Cross Street Washington Street City/StateStockton/CAZip 95203 APN 137.370.02 Property �rr`lo 6111 Bollinger Canyon Rd,Room 3658 San Ramon/CA Owner Chevron/Phillips 66/5T-eKF*tAddress City/State Zip 94583 Phone (925)543-2926 C-57 Contractor National Exploration Wells P md s /�'dPess 1961 Meeker Ave City/StateRichmondlCALic 953646 Phone(510)236-6282 Consultant/Sub Cntr Address City/State Lic Phone Billable Pa Stantec Consulting Services In Rancho Cordov CA Party `Address 3017 Kilgore Road, Suite 100 City/State �ip 95670 Phone(916)861-0400 GIS Coordinates:X Y -(4211 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) O _❑INJECTION(I.e.Air Spame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[INo[IYes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 20,25.49,&50 4 #OF WELL(5)TO BE DESTROYED x❑OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF FT WELL IDs: MW-29, MW-30, MW-32,and MW-33 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS_portland cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:®AUGERS ❑HOSE Q PIPE MUSHROOM CAP AT L3 Fn FT BELOW SURFACE COMMENTS 4 monitoring wells will be destroyed using hollow stem auger an tremie grouted to surface. u ace Will matcn existing grade. 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable Caiifo a-laws. - -- Signed !r' Title/Company Geologic Project Specialist/Stantec Consulting Services Inc. Print Name Alejandra Hernandez Date 11/15/12 // DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS CP6(� Cc) - WC- &e WORK PLAN DATED tR CC K I �)D APPLICATION ACCEPTED BY cio 4 DATE ISS ED t-2 AfEA GROUT INSPECTION BY FINAL INSPECTI N BY nAmp DESTRUCTION INSPECTION BY DATE_ 1 YO ( Z COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE q 2 REQUEST/ PR# $125x 07ZCv'/2 SR# �lP �(O ;�-" 3�7 Roo► -T PR# 2900 C-57 k WC / ' WAIVER V� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 4 EHD 29-01 5/09/12 WELL PERMIT APP