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°0 � SAN .IOAQUIN COUNTY C PdG1 A Ir <br /> �. ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> .. ;� <br /> Y. <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.ora/ehd UNIT IV <br /> L�FOfR� <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 /> City of Stockton ROW Adjacent to 308 S E1Dorado St. <br /> Site Location Cross Street Lafayette and El Dorado. City/State CA Zip 95203 APN City ROW <br /> Property <br /> Owner City of Stockton Address 425 N. E1 Dorado City/State Stockton Zip 95202 Phone 209-937-8366 <br /> C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City/State Sacramento LIC 848359 Phone 916-363-9355 <br /> Advanced GeoEnvironmental Inc. 837 Shaw Road Stockton 680227 209-467-1006 <br /> Consultant/Sub Cntr Address City/State Lic Phone <br /> Billable Party Den Ueda Address 626 East Galin Road City/State French Campzip 95231 Phone 209-462-1262 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(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 O HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑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: ❑AUGERS IJ HOSE El PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> `❑INJECTION(i.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) 65 and 120 <br /> #OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF FT <br /> IDS: MW-8, MW-9 and MW-10 ❑PRESSURE GROUT TO DEPTH OF 65 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland Type I II ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[!]AUGERS EI HOSE El PIPE EI MUSHROOM CAP AT L? <br />