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LJ D..= 's--�SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �....:. :..... . .�, � LOP . { ac. < SITE MITIGATION� ' 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV ��•. ;;;.• Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sictov.orglehd LIppR� ORIGINALWELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT.INVESTIGATIONS AND REMEDIATION 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 2908 W. Benjamin Holt Dr Cross Street Plymouth Road City/State Stockton,CA Zip 95207 APN City ROW Property Owner City of Stockton Address 425 N.EI Dorado Street City/State Sto-ck�tton,CA Zip 95202 _Phone ' C-57 Contractor rji)1eq,0r%1N�J Address �!yP ,L do�41A1'f/n�City/State ' f Lic_1/9'`3165 Phone M25 V3 &0 Consultant/Sub Cntr Stantec Consulting Address 3017 Kilgore Road,Suite 100 City/State Rancho Lic 95670 Phone 916-861-0400 Services,Inc. Cordova,CA Billable Party(consultant) Address City/State Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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 _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(i.e.Air Soarae.Ozonel❑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) 2 #OF WELL(S)TO BE DESTROYED )KC3DIAMETER OF INCHES TO DEPTH OF FT WELL IDs:BHD-2,PR-2 PRESSURE GROUT(see Well Destruction Details Table) GROUT SPECIFICATIONS Neat Cement per SJDEH Guidelines ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE PIPE MUSHROOM CAP AT L?