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SAN .10AQUIN COUNTY <br /> n ov <br /> EORONMENTAL HEALTH DEPARTONT <br /> N. <br /> '• 600 East Main Street, Stockton, CA 95202-3029 TION <br /> �q•;;,;,,;r•1P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www-siaov.orglehd <br /> ��FORt� <br /> 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 /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application ismad <br /> Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> ft* <br /> Site Location 990 Beechnut Ave Cross Street Forest Hill Dr City Tracy Zip 95376 APN 23407001 <br /> Property <br /> Owner. Chevron Address 6101 Bollinger Canyon Rd City San Ramon Zip 94583 Phone925-790-6431 <br /> C-57Contractor PeneCore Drilling Address 1238 Alice St. Suite ACity Woodland Lic 906899 Phone 530-667-4100 <br /> Consultant/SubCntr AMSC Address2101 Webster St. 12th Floor City Oakland Lic 604450 phone 510-663-4100 <br /> Billable Party Chevron Env Mgmt Co Address 6101 Bollinger Canyon Rd City San Ramon Zip 95376 Phone 9 5-790-641 <br /> GIs Coordinates:X Y Please see attached figure <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> XI SOIL BORING IDs AMSC-1, AMEC-2 and AMSC-4 <br /> ❑WELL IDs <br /> ❑ OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE –3" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE of CASING ❑STEEL ❑PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE ElMUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ElAUGERS ElHOSE ElPIPE <br /> 3_�k_[NSOIL BORING ��f,c�,,PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes C5 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑ INJECTION(i.e Air Sparge Ozoned- HAND AUGER GROUT SPECIFICATIONS Type I–II Portland Cement <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 12 r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING ZNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Soil sampling <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES To DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS m�zC I <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California Laws. <br /> Signed izC�'oiu�Jrto. c Title/Company Staff Scientist / AMEC <br /> Print Name Heidi Dietrich–Foronda Date 4/3/12 <br /> po <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I I L 6CH N u'1' <br /> WORK PLAN DATED – C-31 <br /> Z <br /> APPLICATION ACCEPTED BY ,I,y oA�ckr✓I DATE I 12 W REA 1GqF <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE y-23/0, <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> 90 $ 125 X SR# 2 <br /> RO# <br /> 3500 <br /> 2s o3(`� <br /> C-57WC !/WAIVER /l/ 557 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC f,� <br />