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A°`'•" SAN JOAQUIN COUNTY FIE E COP <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Q: a <br /> SITE MITIGATION <br /> ,• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tele hone: 209 468-3454 Fax: 209 468-3433 Web:www.s0aov.or4/ehd UNIT IV <br /> p <br /> /F°R <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. /&2-03co _0`i1 <br /> Site Location )`-305 Cross Street -:J-,4v ,�- <br /> J Q_j City_�-2ov- Zip`352,03 APN i 12 )-- <br /> Property _ <br /> Owner ra��Fv rry H�l> r�n,� +, ?�%-,! ddress 7,0 ;�y - a'Ifj(`1 City k-, -4uo 7a;TXZip Phone 2710- 3115 'Lx,� <br /> C-57 Contractor 6� �,-;��;t7, Address 95"J I-6,,z eA City M-;,4i,,lZ Lic 5i�� Phone92�-'>!3-'��d <br /> Consultant/Sub Cntr L'-L, AIC Address 111-4-L,,,,e P-J,Ave S,,{p 2oi City Lic Phone Z,Y;-5-4c9-222i <br /> Billable Party r,ek..L ATC Address City Zip Phone <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 ❑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 ❑HOSE ❑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 Soarae.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) <br /> _ 1 h #OF WELL(S)TO BE DESTROYED 54 OVER-BORE DIAMETER of '• I INCHES TO DEPTH OF l 1 itS FT <br /> WELLIDs: A3 I "1 10 1411 P S ?-6 . IP-2_'^1Z ❑PRESSURE GROUT TODEPTH 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 />