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ORIGINAL . <br />C-57 V. WC <br />EHD 29-01 5/09/12 <br />0. ENCROACHMENT DOC <br />WELL PERMIT APP <br />WAIVER 41.,/ 1/-') C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />Phone <br />Phone (916) 861-0400 <br />Consultant/Sub Cntr Address City/State Lic <br />Billable Party Stantec Consulting Services Inc istat5ancho CordovnA 95670 Address 3017 Kilgore Road, Suite 100 City <br />PIPE <br />o MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />COMMENTS: Casing Depth: Boring Dia: CONDUCTOR CASING 0 No Yes: Casing Dia: <br />DESTRUCTION WORK TO BE PERFORMED: <br />4 ft OF WELL(S) TO BE DESTROYED <br />WELL Ds: - 9, MW-30, MW-32, and MW-33 <br />GROUT SPECIFICATIONS portland cement <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY). 20, 25, 49, & 50 <br />LE) OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF FT <br />0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />NU MUSHROOM CAP AT (.3 FT), FT BELOW SURFACE <br />d tremie grouted to surface Surface will match existing grade. <br />TREMIE TYPE TO BE USED:Er AUGERS 0 HOSE PIPE <br />COMMENTS 4 monitoring wells will be destroyed using hollow stem auger an <br />LOP <br />1868 HazeIton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: wiArw.sjqov.orgieh UNIT IV <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. <br />Site Location 666 W Weber Ave Cross Street Washington Street City/StateStockton/CAZip 95203 <br />Property her-r96)-- 6111 Bollinger Canyon Rd, Room 3658 San Ramon/CA Owner Chevron/Phillips 66/ -5-rxekIntAddress City/State <br />C-57 Contractor National Exploration Wells P n as e 1961 Meeker Ave City/State RIchmond/CAZ <br />94583 <br />995364 <br />Phone (925) 543-2926 <br />6 Phone (510) 236-6282 <br />GIS Coordinates: X <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />0 SOIL BORING IDs <br />0 WELL IDs <br />El OTHER IDs <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE <br />CASING THICKNESS <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: 0 Yes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />TYPE & # OF WELUBORING <br />0 MONITORING <br />CI EXTRACTION: Vapor/ Water <br />D SOIL VAPOR PROBE <br />O SOIL BORING <br />INSTALLATION TYPE <br />Ej HOLLOW STEM <br />0 HAMMER/DRIVEN <br />O MUD ROTARY <br />0 PUSH POINT (GP/ CPT) <br />O INJECTION (I.e Speras Ozone) 0 HAND AUGER <br />OTHER: 0 OTHER: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />APN 137.370.02 <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />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 <br />Regulations, and all applicable Callfmtalaws. <br />Signed <br />Print Name Name Alejandra Hernandez <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS &act we <br /> <br />/1444CCU f ) 2A/C) // fri If ,2o/Z. <br />j.1 io g <br />. . .1 <br />DESTRUCTION INSPECTION BY <br />FINAL INSPECTlyN BY <br />DATE <br />WORK PLAN DATED <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY n.A1E <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK fr RECV'D BY DATE SERVICE <br />REQUEST <br />RO ft <br />PR* INVOICE <br />$ 125 x LI 9% <br />73 <br />32 36 7? cuiu ora-, e.)-2L ,-/2 6 SR# 6 1 1-i / <br />C) .) 7T 571 RO # <br />(3500) <br />PR # <br />(2900) <br />(t) <br />Title/Company Geologic Project Specialist/Stantec Consulting Services Inc. <br />Date 11/15/12