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P-Y SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP '. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.siaov.org/ehd UNIT IV 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 2905W.Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN 097-600-04 Property Houston, Owner Chevron USA, Inc. Address P.O.Box 285 ,p City/State TX Zip 77001 Phone ' C-57 Contractor '�✓C Dh(I i tjl _ Address q0#,-#,Va1&J fPjgj; Z City/State ' 6A _Lic•N8S/9 Jam_Phone 11105)313 --5 Consultant/Sub Cntr.St ntec Consulting Address 3017 K/iIgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 Billable Party(consultantServices,Inc. Address City/State Cordova,CA Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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) _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX" OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING[INo ElYes: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_ 6 #OF WELL(S)TO BE DESTROYED MR OVER-BORE DIAMETER(see well Destruction Details Table) WELL IDS: MW-1R,MW-2R,MW-3R,MW-5R,MW-7R,MW-9R PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: Z AUGERS ElHOSE X 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 I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations, nn�dall applicable California laws. SignedAr�� Title/Company Senior Geologist Stantec Print Name Shane Olton Date "Z r� DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED a APPLICATION ACCEPTED BY J +c AREA GROUT INSPECTION BY FINAL INSPECTION BY ATE ZS-/ DESTRUCTION INSPECTION BY DATE ), COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 0 $125, �J`O,QG7 3��•�J``-� 1 �/ SIR (3500) i PR# g (2900) 57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC1-" =HD 29-01 5/09/12 AA1c1 i DMOR1.1 ADD