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L' f IS <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> == :• 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> •.. ;:. :� Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sigov.orgleh UNIT IV <br /> FO <br /> WELL & BORING PERMIT APPLICATION <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 EQviro en I Heallh Department <br /> L % `� <br /> Site Location zoo Lt).C wcki SF Cross Street L'i YgC� City/Slate Ctl ZipCg6265 APN <br /> 9ZA <br /> ) yY- 23-6) j <br /> Property 'P OwneruQLv LY�C � Address City/StatehW Phone <br /> - - � d� l - 7& .7'(- <br /> C-57 Contractor 01-UI .1��ddress UY City/State ' Lic W6k0'7_ <br /> Phone` SI� <br /> Consultant/Subtt,ncr Address IDb Lts-Sc>yl rldnSt City/Stalek-�/U.'72a Z2.12.0 P h,n,Yobs•34 7•ySB� <br /> Billable Party Address `� " City/State N zip Phone ~ <br /> GIS Coordinates:X 3 .9q 5 I Y <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW vvm_7D0M&11'i(CPT,-GEDPKOS_E�SYDROPUNCH;liAi{fl AtjGER OTtiEt� <br /> SOIL B <br /> ORIN IDs`` - <br /> RWELL <br /> IDs -Gj� �� 55 A11tJ-3- /Y!!l1 -5 R/ll?GG+-4f. • - �hI/L+tj <br /> OTHER IDs rJD MW- � P,- fs n1 w- /�� -•1 �_I�J-�l -LI G1 GtJ-� � / <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> LL MONITORING HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL,,/WELL C =CG Oa <br /> -[-I EXTRACTION:Vapor/Water [Il7 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL PVC Q OTVCM <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AIJGCR3 Q IC= ❑PIPE <br /> _❑SOIL BORING 7/?USH POINT(G,P�/CP�T)� GROUT SEAL PUMPED:❑Yes El No(MAXIMUM FREE FALL DEPTH IS 39 FT) <br /> _❑INJECTION 0 e.Air Sparge.Ozone][+ HAND A�j�� GROUT SPECIFICATIONS <br /> _❑OTHER: []'OTHER-_ J APPROX.BORING DEPTH ❑BOLTED TRAFFIC D= C7 Q^:MW PIPE <br /> CONDUCTOR CASING❑No❑Yes: Dia: Casing Depot CafC3:,-:� <br /> COMMENTS: �-L � I.UCCAS �?� �5u{�ST_!T-SkolIIrm-a -ac-r bmf <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PVtAL 0 <br /> _DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLn <br /> #OF WFI BE DESTROYED Ll OVER-BORE DIAMETER OF INCHES TO 004 lrmOfFT <br /> WELL IDs: n PRESSURE GROUT TO VFPTH OF_ _IT�a tAJXFACE <br /> GROUT SPECIFICATIONS [ EXPLOSIVES FROM, TO '_FT C'31=7 CiuVWACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT f? <br />