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SAN JOAQUIN COUNTY ORIGINAL ENVIRONMENTAL HEALTH DEPARTMENT LOP Ul: :i �• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION �n = UNIT IV Foa` Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/ehd 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 Zip95207 APN 077-480-14 Property Phillips 66 Address 1380 San Pablo Ave. City/State Reno,CA Zip 94572 Phone 510.245.4423 Owner C-57 Contractor Address City/State Lic Phone Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave.,Suite 201B City/State Modesto,CA Lic 95351 Phone 209.579.22,t 1 Billable Party Cardno ATC for Phillips 66 Address 1117 Lone Palm Ave.,Suite 201 B City/State Modesto,CA Zip 95351 Phone 209.579.227./ GIS Coordinates:x 38.019 Y-121.324 .3Af`j X0 —121. 3211 - CONSTRUCTION WORK TO BE PERFORMED: [:1 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs P]WELL IDs MW-12R ❑OTHER IDs TYPE 8r#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ONITORING�0*9/V/�yO 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 a 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 surroiindi g well box will he replaced NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELLS)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 ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED ](A;,y ;ZL APPLICATION ACCEPTED BY J, y a/gK.LAW' � DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ✓ M W — ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# $125x / 25 POI&uKiT,MF 7 Z9'y SR# RO# p (3500) PR# (2900) C-57 _4_ WC ✓ WAIVER A14 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC P, n�4.ni sinwi? WELL PERMIT APP