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ORIGINAL <br /> oP°`'"�•.c SAN JOAQUIN COUNTY <br /> �. a„Ft ••o <br /> -,��- ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N: a <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> � UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sidov.or-q <br /> �I FORS% <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. R04j <br /> Site Location 7647 Pacific Avenue Cross Street Rivara Road City/State Stockton,CA Zip 95207 APN 077-480-14 <br /> Property Phillips 66 1380 San Pablo Ave. Reno,CA 94572 510.245.4423 <br /> Owner p Address City/State Zip Phone <br /> C-57 Contractor Gregg Drilling&Testing,INC Address 950 Howe Rd. City/State Martinez,CA Lic 485164 Phone 925-313-5800 <br /> Consultant/Sub Cntr Cardno ATC Address 1117 Lone Palm Ave.,Suite 201B City/State Modesto,CA Lic 95351 Phone 209.579.221 <br /> Billable Party Cardno ATC for Phillips 66 Address 1117 Lone Palm Ave.,Suite 201B City/State Modesto,CA Zip 95351 Phone 209.579.221 <br /> GIS Coordinates:X 38.01921 Y -121.32418 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> 0 WELL IDs MW-23 <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING ❑� HOLLOW STEM DIA.OF BOREHOLE 8 in ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING D <br /> IA <br /> sch.40 TYPE OF CASING: ❑STEEL E]PVC ❑ OTHER <br /> —❑EXTRACTION Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: ❑AUGERS ❑O HOSE El PIPE <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:O Yea Cement QfOUt M FREE ALL DEPTH IS 30 FT) <br /> GROUT SPECIFICATIONS <br /> _❑INJECTION(i e Air sparge.Ozones E]HAND AUGER <br /> ❑OTHER: APPROX.BORING DEPTH 55-60 ft 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑OTHER: <br /> CONDUCTOR CASING❑� No 13 Yes Casing Dia: Casing Depth: Boring Dia. <br /> - <br /> COMMENTS:Well installed � ^rarrtno s Work Plan <br /> f Anrnfinn I Srnl and C`rnundwter Assessment"dated August 12 2014 <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> S <br /> DESTRUCTION METHOD(CHECK ALL THAT APPS FT <br /> DESTRUCTION WORK TO BE PERFORMED: INCHES TO DEPTH DF <br /> ❑OVER-BORE DIAMETER of FT BELOW SURFACE <br /> #OF WELL(S)TO BE DESTROYED p PRESSURE GROUT TO DEPTH OF,FT BELOW SURFACE <br /> WELL IDs: E] EXPLOSIVES FROM TO FT BELOW SURFACE <br /> GROUT SPECIFICATIONS E] MUSHROOM CAP AT(>3 FT) <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑ PIPE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFITER PEe work VRMIill eTdne in IoSSUANCaccoE) FOR ce tN San JoagON Co Puin O nty Ordinances, Rules and <br /> I hereby certify that I have prepared this application and that <br /> Regulations all applicablip California laws. Title/Company <br /> Cardno ATC <br /> Signed Date 12/17/2014 <br /> Print Name <br /> Je ne Hornsey v <br /> DEPARTMENT USE ONLYJ��� <br /> 7 7 r9av <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS / <br /> WORK PLAN DATED DATE I EA <br /> APPLICATION ACCEPTED BY BY <br /> DATE <br /> FINAL INSPECTION <br /> GROUT INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> COMMENTS/CONDITIONS: <br /> FAC# SERVICE RO# INVOICE <br /> ACCOUNTING ONLY: AID# <br /> RECV'D BY REQUEST PR# <br /> PE CODES FEE INFO AMT REMITTED CHECK# DATE /'� SR# /Z-3 <br /> 23 �'t~lv ^�- S RO# <br /> 3500 <br /> 353 PR# <br /> 2900 <br /> WC _WAIVER._ _ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ WELL <br /> ENCROACHMENT DOC_ERMIT APP <br /> C-57 V <br /> EHD 29-01 5/09/12 <br />