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e .In SAN JOAQUIN COUNTY ILL ENVIRONMENTAL HEALTH DEPARTMENT LOP" SITE MITIGATION •; d .•`. 600 East Main Street, Stockton, CA 95202-3029 UNIT IV • Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siciov.org/oh C!F � WELL & BORING PERMIT APPLICATION 1-4 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION S� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .i I 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 0 bpi I/f6:c.�+ fury.Cross Stree�t-�, -�Jr' /+��(n✓a7 P City `�[Vj1-h n: Zip �. APN L > OwneProper ' r•^(�'�I 09��/ Address 70 t' /"�'ih City � �. Zip _Phone <� ! Address / 1«vj/<"�.h `City nc/'fiY Llcy Phone/ G�� 3��60 ' C-67 Contractor - } ConsultanVSubCntr Address /��u� ,r �. City tnA 'Lic cc�� Phone Billable Party�inp[nf�t9l"K, s Address, (J fid« - city �flr='z^K�'fp Zip !�p(L Phone GIS Coordinates:x 37 985- Y %21 .3V6 CONSTRUCTION WORK TO BE PERFORMED: " - .. ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs - ❑WELL IDs ❑OTHER IDs - TYPE&#OF WELILBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE_ ❑MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA:_ ❑EXTRACTION:Vapor/Water ❑HAMMERlORrVEN CASINGTHICKNESS TYPE OF CASING: O STEEL ❑PVC O OTHER ❑SOILVAPOR PROBE C1 MUD ROTARY DEPTH OF GROUT SEAL. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE r SOIL BORING Cl PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION(I AS 0 1El HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE 1 CONDUCTOR CASING❑No❑Yes:Casing Ois:_Casing Depth:_ Boring Dla:_ COMMENTS: NOTE: OFFSITE WELLS&'BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BEPERFORMED: DESTRUCTION METHOD;(CHECK ALL THAT APPLY) #OF WELLS)T9 BE DESTROYED _ __ __ / ]OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: Sr F y— ,3 11= Fr 5 ( ) (= ff PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM - TO FT BELOW SURFACE TREMIE TYPE TO B ED:❑ UG RS ❑HOSE ❑PIPE ❑MUSHROOM CAkT f?