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SAN JOAQUIN COUNTY <br /> EONMENTAL HEALTH DEPARTfNT LOP. l <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> c�•.:-,� t-..•; Telephone:(209) 4613-3454 Fax: (209) 468-3433 Web:www.sinov.orctlehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> r - _ <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 Zara 3R3-"or-jr. i Cross Street V4yt-04,' ?A>. City "32 1 ZipK�o T. APN <br /> Property <br /> owner SAN9p6u�u4a�.hyiMasaolyn Address X59 Se�rwllh+.+�nT ✓11'Y City �irlackT-aa Zip°IiC'TioG Phone <br /> C-57Contractor �o.0 _ Address ISD ikwT, 0-2 - City fttxr►tj." Lidtil4rl�. Phone I25"Sf3 SY°� <br /> Consultant/Sub Cntr C/e4r. Address h a 7,5.0 City' Lid Phone3<10.4-01I's 3V-y&-0 <br /> Billable Party CAA Address City Zip Phone <br /> GIS Coordinates:X 'Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> —[3 EXTRACTION:Vapor]Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: El AUGERS [I HOSE ❑PIPE <br /> ____❑SOIL BORING �•.❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED: ❑Yes C]No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> ❑INJECTION(i-e.Air Soarae.Ozonel©HAND AUGER GROUT SPECIFICATIONS <br /> _._❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing pia: Casing Depth: Boring Dia: <br /> COMMENTS: N: <br /> NOTE: OFFSITE WELLS $ BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> ] <br />` --#OF WELL(S)TO BE DESTROYED CK-OVER-BORE DIAMETER OF INCHES TO DEPTH OF '3 FT <br /> WILL IDS: MIN' d2 PRESSURE'GROUT TO DEPTH OF' 3 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ,4.2IPE (MUSHROOM CAP AT.(? <br />