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r <br /> o <br /> Aa"' • SAN JOAQUIN COUNTY O � <br /> t ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION . <br /> i( •: `• 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV ) <br /> t� <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sinov.org/ehd <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 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 2908 W.Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton.CA Zip 95207 APN 097-630-32 <br /> Property Buena Park, <br /> Owner BP West Coast Products LIc. Address�pPr�..O,,.Box 50155 City/State CA Zip­22622 Phone <br /> C-57 Contractor &i Dri/1%n Address 77�>�Ve� ®��-4tyCity/State GA- _LicY351v5=_Phone ft5)513-506 <br /> Consultant/Sub Cnt�"antec CansTiiting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 <br /> Services,Inc. Cordova,CA <br /> Billable Party(consuuanl) Address City/State Zip Phone <br /> a 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 /> 5 ❑OTHERIDs <br /> 1 TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1 <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.AirSuaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX,BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> A 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: ES(fSTTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> 31 #OF WELLS)TO BE DESTROYEDE-2,E-3,E-4,E-5,E-6,E-9,E-10,E-11,E-12,MWA,MW- - OVER-BORE DIAMETER(see weu OeslrucGon Detvls Tab:e) <br /> WELL IDS:y-1,V-2,V-3,V1,V.S.V-6,V-TV 8,V-91S-7,V10lSS,V-11,V-12,S-1,S-2,S-3,S-4,S-5,S-6,S-9 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>4 PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signed ��"' _ Title/Company Senior Geologist Stantec <br /> Print Name Shane Olton Date -7 if <br /> DEPARTMENT USE ONLY <br /> S SITE MAP IN UNIT IV FILE-SITE ADDRESS Q� Z/ <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED 0K DATE ISSUED���,'-' 1AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> k COMMENTS/CONDITIONS: <br /> a ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> SQ $125x,�V00 --3 Z- SR <br /> I RO# <br /> 7�00 7 07 / 3500 <br /> PR# <br /> 2900 <br /> ! C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> I EHD 29-01 5/09112 WELL PERMIT APP <br />