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RECEIVE=- <br /> SAN JOAQUIN COUNTY NOV 18 2L URIGINA 'L <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> !" `I uNMENTALH'SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 nr.AIT,�- UNIT IV <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sigov.org/eh <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 500 East Louise Av8ross Street Harlan Road City Lathrop Zip 95330 APN 198-120-09 <br /> Property PNA-Lathrop 811 Madison Ave. Toledo, OH 43604 <br /> Owner p Address City Zip Phone <br /> C-57 contractor AGE Address 837 Shaw Road cityStockton,CA Lic 680227 Phone 2094671006 <br /> Consultant/Sub Cntr Address " " City " " Lic Phone <br /> Billable Party Reynolds/Brown Address 1200 Concord Ave city Concord, CAip 94520 Phone 9256748400 <br /> GIS Coordinates:X Y `1 Z(, Suite 200 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> )ROIL BORING IDs B# to B# (approximately up to 20) <br /> ❑WELL IDS <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE2 InCh ❑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 30 ft TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE PIPE <br /> —jX SOIL BORING X PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e AirSparge,ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 30 ft ❑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) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT L? <br />