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q�IN CRIGINA "� ,oP .0oG SAN JOAQUIN COUNTY 2 - ? ENVIRONMENTAL HEALTH DEPARTMENT LOP �. 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • c. P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.smgov.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. ;Z4 2,090-!S Site Location 174 W Aldrich Cross Street Shields City/State Mountain FLWse 95304 APN 299.6A4-9429.._. Property Owner Shea Mountain House LLC Address 2630 Shea Center Drive City/State Livermore,gipA 94551 Phone 925-245-3600 C-57 Contractor V&W Drilling Address 3806 Duck Creek Drive City/State Stockton,CAc 720904 Phone 209-469-7700 Consultant/Sub Cntr ENGEO Address 580 N Wilma City/State Ripon,CA Lic Phone 925-525-4421 Billable Party Shea Mountain House LLQddress same as above City/State Zip Phone GIS Coordinates:X 37.764129 Y-121.549511 7 </ / -r 1f CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF "50 FT WELL IDs: N/A ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS neat cement ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE X❑ PIPE ❑MUSHROOM CAP AT L?