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Pa"I" SAN .�OAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTIv,CNT ¢� � SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV FC—Uphone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.org/ehd �/FOR AUG I I �Uld WELL & BORING PERMIT APPLICATION ENVIRONM.EN7 YYH-LS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION PERMIT/SERVICES 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. Site Location �3 /%✓/✓76�' �`Q Cross Street ��%�k '44 • City J;�('Y Tam Zip �5a�'a APN /y 9' "0 -0 E' Property C o 7wE W.cv s>A'C ,Poc/ E.e/c ?? Owner/00 OAKrT/e6Er- Coe/A dress 4/630 my yTcc o7eFRYA✓;City� AA��Zip•.A0b/1 PhoneSc/'65l 1584/0 C-57 Contractor V4414 E'/! JF!✓ioF.4gddress/J'yg-EE1' 4-7Wct T City�e,-�'CLEy Lic 916ogs Phone y1.5-- Consultant/Sub Cntr NwYo E' 40.0 QE Address /956CJL/�,t>c.0 JT City oA,C,[A.r/v e4 Lic Phone-o Billable Party 3tnala ctA[Ce7Vc�I Address?ZFTA)-Ch,4*Yi0S - Ste-?DF city lhw6ai+At zip-9 I S Vq Phone GIS Coordinates: s44 ° J-yG5 ! './-7- `'/1"'~, CONSTRUCTION WORK TO BE PERFORMED: [F NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) (krSOIL BORING IDs IS-e-.2 JB - 3 ❑WELL IDs 2*OTHER IDs J/-/ ✓- , J-✓- 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 I91fOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS E]HOSE ❑PIPE ,L2-901L BORING 9j USH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a 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 INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L?