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�. COP 'S 4D'7. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION � P Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.siaov.org/eh UNIT IV � FORN 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 666 W Weber Ave Cross Street Washington Street City/StateStockton/CAzip 95203 APN 137.370.02 Property �rtYo 6111 Bollinger Canyon Rd,Room 3658 San Ramon/CA Owner Chevron/Phillips 66/$T+rCX4ddress City/State zip 94583 Phone (925)543-2926 C-57 Contractor National Exploration Vels PAT.Press 1961 Meeker Ave City/State RichmondlCALic 953646 Phone(510)236-6282 Consultant/Sub Cntr Address City/State Llc Phone Billable Party Stantec Consulting Services In ddress 3017 Kilgore Road,Suite 100 City/Stateancho Cordov�CCA 95670 phone(916)861-0400 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER L� _0 SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE )oX^\ _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) o _0 INJECTION fl.e Air eters..ozone)D HAND AUGER GROUT SPECIFICATIONS _❑OTHER: D OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING D No D Yee:Casing Dia: Casing Depth:_ Boring Dla:_ COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS �I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 20,25,49,&50 m 4 #OF WELLS TO BE DESTROYED ©OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF FT rD WELL IDs: MW-29,MW-30, MW-32,and MW-33 El PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS oortland cement ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:Fel AUGERS ❑HOSE q PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 4 monitoring wells will be destroyed using hollow stem auger and tremie grouted to surface. Sur ace wl mac existing grade. m 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 Califo a-laws. Signed Title/Company Geologic Project Specialist/Stantec Consulting Services Inc. Print Name Alejandra Hernandez Date 11/15/12 // /`DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITEADDRESS (P IPI¢ Cel , WC-&p_ WORK PLAN DATED 41w1e0-14 [I 2A)C) 44VJ ray /(12o/Z APPLICATION ACCEPTED BY ' t' 0 4 KLL WI r DATE ISSUED !(•(G•f 2 AREA /GTr9 GROUT INSPECTION BY '�"'" FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY L 4"dl dJ4 DATE %- j tdl'C '� eL Zbl It COMMENTS/CONDITIONS: LK111V Mb Z •5J W Z AI�US3 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE q REVUE/ST/ P/R1# 2q 0 Z $125, 26-12 SR# tP IP " I I �• l 3�J 377 RO# 3500) PR# 2900 C-57 ✓ WC (-_WAIVER VZ16 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC EHO 29-01 5/09/12 WELL PERMIT APP