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IN COUNTYORIGINAL <br /> SAN .10AQU u <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> •: 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •.- �, UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:vii iclov.ora/ehd <br /> ��ti bri <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 madeto San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 2905W. Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN 097-600-04 <br /> Property Houston, <br /> Owner Chevron USA, Inc. Address P.O.Box 285 `� City/State TX Zip 77001 Phone <br /> C-57 Contractor `(✓ Q Dr1Ili�h_ Address 90&iJ&i X,f4Ae Z City/State ' 6,A _Lic,Lj7Q657 Phone&Z-5)3;13 <br /> Consultant/Sub Cntr St ntec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 <br /> Billable Party(consu:tantServices, Inc. Address City/State Cordova,CA Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge.Ozone)❑ HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THATAPPLY <br /> 6 #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER(see Well Destruction Details Table) <br /> WELL IDS: MW-1R,MW-2R,MW-3R,MW-5R,MW-7R,MW-9R PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑ HOSE X PIP MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <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, nndd-all <br /> laapplicable California laws. <br /> Signed �o Title/Company Senior Geologist Stantec <br /> Print Name Shane Olton Date <br /> �7C`DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS -2 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY 34 VVIIII FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY-3.171g2/j /le e?�✓`� DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RID# INVOICE <br /> / REQUEST PR# <br /> 5:50 SR <br /> Roo .3 <br /> PR# <br /> g 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC/-' <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />