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© r-:9 SAN .10AQUIN COUNTY ORIGINrl`��" `z ENVIRONMENTAL HEALTH DEPARTMENT LOP X N: < Ilia '•� 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION UNIT IV „cq•.,,,., .�;;P Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.siaov.org/ehd LI FOR 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 34701 S.Welty Road . Cross Street Highway 33 City/Slate Vernalis Zip 95385 APN 255-180-15 Property Owner Karnail Sandhu Address 3972 W Durham Ferry Road City/Slate Tracy Zip 95304 Phone (209)612-1127 C-57 Contractor Penecore Drilling Address 123E Alice Street,Suite A City/State Woodland Lic 906899 Phone (530)661-3600 Consultant/Sub Cntr SAIC Address 1000 Broadway,Suite 675 City/State Oakland Lic N/A Phone (510)466-7148 Billable Party SAIC(see above) Address City/Stale Zip Phone GIS Coordinates:X -121.29056 Y 37.63480 c': .3 -- CONSTRUCTION WORK TO BE PERFORMED: -1-1i ®NEW WELLBORING(CPT GEOPROB YDROPUNCH,HAND-AUGER,OTHER) C ®SOIL BORING IDS SB-7 SB-8&SB-9 ❑WELL IDS ❑OTHER IDS TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" [:)MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Surface TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE RI PIPE (]�� 3 ®SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ©No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(,a.Air Sparge.Ozwel❑HAND AUGER GROUT SPECIFICATIONS Tremie grout with neat cement to surface ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 50 feet bgs ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:Fieldwork is on behalf of Chevron Site name: Ahern Road-Vernalis(SJCEHD reference address=35500 Welly Road) NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and all applicable Calif ia laws. Signed � _ _ � _ Title/Company Project Geologist/SAIC Print Name Sean Gehlke Date 11/14/2012 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 3 5-7 O 4, VC-R N 9L-1 5 WORK PLAN DATED k 8 U APPLICATION ACCEPTED BY U�}Ku� DATE � +" / >v,. � GROUT INSPECTION BY FINAL INSPECTION BY 4 (� ��Q�E DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIO NS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# C1 125X / 2500'4 C7-2 rl-1 - 2 SR# ?j 3�� RO# O 350D PR# 2900) C-57 WC ✓ WAIVER 1k) ff— C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT v ENCROACHMENT DOC A-14 EHD 29-01 5/09/12 WELL PERMIT APP