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i <br /> l <br /> SAN JOAQUIN COUNTY ORIGINAL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> . L lephone: (209) 468-3454 Fax: (209)468-3433 Web:www.si4ov.orglehd UNIT IV <br /> ��;�..::••�T HEA <br /> NV�IZ WELL & BORING PERMIT APPLICATION <br /> F��M4YISE4t�10ES <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 /> SiteLocatlon 94 Castle Street Cross Street pacific Avenue City Stockton Zip 95204 APN 125-60-04 <br /> Property I <br /> Owner Robert Scott II Address 120 23rd Avenue City Stockton Zip 95062 Phone N/A <br /> C-57 Contractor All Well Abandonment Address 9245 Beatty Drive Suite A City Sacramento Lie 848359 Phone 1-916-363-9355 <br /> Advanced GeoEnvzronmenta Inc. 837 Shaw Road - Stockton 680227 209-967-1006 <br /> Consultant/Sub Cntr Address City Lie Phone <br /> Billable Party David Atwater Address P•o. Box 1107 City Stockton Zip CA_ Phone 209-944-9115 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs ' <br /> ❑OTHER IDs <br /> TYPE R#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS f <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF 60REHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapod Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY :, DEPTH OF GROUT SEAL` TREMIE TYPE TO BE USED: 0 AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) f <br /> _❑INJECTION(i.e.Air SDarae.Ozone)❑HAND AUGER_-GROUT SPECIFICATIONS 1I <br /> _❑OTHER: ❑OTHER: i APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Baring Dia: I <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 #OF WELL(S)TO SE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: MW 10 ®PRESSURE GROUT TO DEPTH OF 40 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Portland Type II/IV ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS x❑HOSE ®PIPE E)MUSHROOM CAP AT 1? <br />