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�o �o SAN JOAQUIN COUNTY ORIGINAL ENVraONMENTAL HEALTH DEPARTM15NT LOP •• '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �q•. - Telephone: 209 468-3147 Fax: 209 468-3433 Web:www.sigov.org/eh S30M18- 111Wd3d P b.1N31NN081AN3 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONVIR 8 0 130 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 m e r4=�wfth�l Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Departm V� Site Location 7647 Pacific Ave. Cross Street Rivara Rd. City/State Stockton,CAZIp 95207 APN 077-480-14 Property Owner Phillips 66 Address 1380 San Pablo Ave. City/State Rodeo Zip 94572 Phone 510-245-4423 C-57 Contractor Gregg Drilling&Testing Address 950 Howe Rd. City/State Martinez,CALic 485165 Phone 925-313-5800 Consultant/Sub Cntr Cardno Address 1117 Lone Palm Ave.,Ste.201 City/State Modesto,CALic Phone 209-579-2221 Billable PartyCardno for Phillips 66 Address 1117 Lone Palm Ave,Ste.201 City/State i Lujc&La ['AZip 94549 Phone 209-579-2221 GIS Coordinates:X 30,o 19 2( Y CONSTRUCTION WORK TO BE PERFORMED: ® NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs x❑WELL IDs AS-1,VWl,VW2,VW3 ❑ OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑) HOLLOW STEM DIA.OF BOREHOLE 8 in. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 3 p EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS sch.40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 20-40 ft. TREMIE TYPE TO BE USED: ❑AUGERS El HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) I IT INJECTION(i.e Air Soarfle.Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement grout ©OTHER: ❑OTHER: APPROX.BORING DEPTH 4n-r,()fr ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia', COMMENTS: Wells installed as described j12 C;ar no's"Work la nAi� s ' 7 ,p pp ��ss /r✓u( NOTE: OFFSITE WELLS & BORINGS REQUIR AC ESS AGW9EE EI TS E{I�C �ACH t 'I ioi i DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APPLYI #OF WELL(S)70 BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH T OELOW SURFACE WELL IDs: [I PRESSURE GROUT TO DEPTH OF GROUT SPECIFICATIONS ElEXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ElAUGERS [IHOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 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,and all applicabl California laws. /� �/I -FC Signed Title/Company CQ V (rT Print Name - ;� Date O O EPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS 7� �7e N a S T6e'CT-b'1 WORK PLAN DATED t46-u5 r 12 2-ol U APPLICATION ACCEPTED BY f- of9'K-u DAT AREA Q GROUT INSPECTION BY ,_ FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: f rG1 e - S i6i ONLY: AID# FAC# SERVICE RO# INVOICE FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# $130X / l G !0UV-%P 9 SR# 70766 EEEE CC RO# 3 5 3 1C� 3500) 557 PR# (2900) �C5;7��w _ _WAIVER�� C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENWDO P MIT APP F H n 99-11 7124114