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• 0 FILE Copy xoe4 .� SAN JOAQUIN COUNTY r` ? ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION •.- - :� Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.siaay.org/eh UNIT IV 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 /�rryo 6111 Bollinger Canyon Rd,Room 3658 San Ramon/CA Owner Chevron/Phillips 66 5T>dK lddress City/State Zip 94583 Phone (925)543-2926 C-57 Contractor National Exploration Pkr�pess 1961 Meeker Ave City/State Richmond/CALic 953646 Phone(510)236-6282 Consultant/Sub Cntr Address City/State Lie Phone Billable Party Stantec Consulting Services Inr 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 WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE_ ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: _D EXTRACTION:Vapor/Water D HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER [� _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS ❑HOSE D PIPE 6X� _D SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _D INJECTION(I.Ar Spero.,Ozone)D HAND AUGER GROUT SPECIFICATIONS _D OTHER: D OTHER: APPROX.BORING DEPTH D BOLTED TRAFFIC BOX OR []STOVEPIPE CONDUCTOR CASING❑No D Yea:Casing Die: Casing Depth:_ Boning Dla: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 20,25,49,&50 4 #OF WELL(S)TO BE DESTROYED D OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF FT WELL IDs: MVV-29, MW-3D, MW-32, and MW-33 ❑PRESSURE GROUT TO DEPTH OF FTBELOWSURFACE GROUT SPECIFICATIONS portland cement ❑EXPLOSIVES FROM ro FT BELOW SURFACE TREMIE TYPE TO BE USED:Rl AUGERS ❑HOSE q PIPE MUSHROOM CAP AT L3 Fn FT BELOW SURFACE COMMENTS 4 monitoring wells will be destroyed using hallow stem auger an tremie grouted t0 surface. ur ace wl mac existing grade. 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 CaliaJaws. Signed Title/Company Geologic Project Specialist/Stantec Consulting Services Inc. Print Name Alejandra Hernandez Date 11/15/12 // //j/DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS IPlF L2 Lc) • WC-- &Q WORK PLAN DATED Mi4 leCI1 rl ZLID Mr'./l /l, 2,317— APPLICATION ACCEPTED BY X14. �o B"Cu-wl DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE 1,111 N, I'l a tb(to 12 COMMENTS/CONDITIONS: A-ViE' W1 t A 4 7 t) to w 2 3 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE C] �j / REQUE/ST// PR# d� IOL $125x — 3� 3vF 7 C64KIf ( !(J-2(o-l2 SR# r1 4O 37- 371 RD# I 3500) PR# 2900 C-57 ✓ WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT / ENCROACHMENT DOC /✓Tyr EHD 29-01 5/09112 WELL PERMITAPP