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SAN JOAQUIN COUNTYFILF• COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP •' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 $TTA IMITIGAT Ct �P Telephone: (209) 468-3454 Fax: (209) 468.3433 Web:www.s' ov.or /e6d s'UNIT�l �1�a'sk►' WELL & BORING PERMIT APPLICATION 2013 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES_1 YEAR FROM DATE ISSUED ,ciiie'L HJE ^,Ift-T Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made i4iii Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin Coouuntty,Environmental Health Department. Site Location t$ t��"��5`/Cross street Il S 9 h ►' ty'amu • r5Zp7 � Ci Zip APN � � poz9�Q � owner n ti�� `Atfd'ress� 0 Q tix D t D city ZIP 1 a� Phone 0 C-57 Contractor e' Address � VJ City '�riiA $ Lic !S' Phones Consuttant/Sub Cntr 6. \' Address Al Cri�� .t City {r d 0" Lic Phone 710 r3 Billable Party ��,.�\' Address? it00 law e' .k City tl, f V� zip k44�Phone C1(4 GIS Caordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: NEW WELIIBORING(CPT,GEOPROBE,HYDROPUNCH• D-AER,OTHER) _r]. Il_BORING IDs LJ WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING 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 5_SOIL BORING Pq11SH POINT(GP!CPT) GROUT SEAL PUMPED:[]Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.a AirSppme. on, eTsl ANp AUGER GROUT SPECIFICATION5 _❑OTHER: 0 OTHER: APPROX-BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING C]No[IYes:Casing Dia: Casing Depth: Baring Dia; COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH (CHECK ALL THAT AP LY #OF W ELL(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�?