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ut 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.sigov.org/ehd UNIT IV 4�/FOFRa 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 7647 Pacific Avenue Cross Street Rivara Road City/State Stockton,CA Zip 95207 APN 077-480-14 Property Phillips 66 Owner p Address 1380 San Pablo Ave. City/State Reno,CA Zip 94572 Phone 510.245.4423 C-57 Contractor Address City/State Lic Phone Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave.,Suite 201 B City/State Modesto,CA Lic 95351 Phone 209.579.22,1:l Billable Party Cardno ATC for Phillips 66 Address 1117 Lone Palm Ave.,Suite 201 B City/State Modesto,CA Zip 95351 Phone 209.579.22 / GIS Coordinates:X 38.019 Y -121.324 33TO(9 j.A -12f, 32y;.9 CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs I]WELL IDs MW-12R ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING f'07 q/4//Y❑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 CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: Deteriorating cement skirt surrounding well box will he replaced NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ 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,and all applicable California laws. Signed Title/Company Environmental Technician/Cardno ATC Print Name Genelle Martin Date / DEPARTMENT USE ONyLY, SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED u ZU/moi nwwb APPLICATION ACCEPTED BY KL4W, DATE IS J"OEA GROUT INSPECTION BY FINAL INSPECTION BY m "ATE �Z-tfi y DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY. AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE 1G REQUEST PR# h�« $125x / 25 vi3g A6Lou+vT)9* 7-Z9'Icl SR# 7 RO# _ (3500) 0 S; PR# (2900) C-57 4 WC ✓ WAIVER A/& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT .✓4 ENCROACHMENT DOC A'Y4 EHD 29-01 5/09/12 WELL PERMIT APP