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�ukLy �A SAN JOAQUIN COUNTY EN NMENTAL HEALTH DEPARTMOT LOP � SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT N dq.- _:,a�P• Telephone. (209) 468-3454 Fax: (209) 468-3433 Web. www.sigov.orq/ehd RECEIVED WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIONJUN 17 �01 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 "pff t h San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmer ?�RMIT/$ERVL�C�E"a Site Location J�15'D (), IF/LEMI&NTCr�Street Pr-&ROL,-kAlt r� City �Troc. TD4 Zip 4�d03 APN /335P 9;(5 Property T Owner -7—Me P1CKCtS $u��bA�dre Pd aox 1dGO City 5YDC,ie-7 Zip 12� Phone ?74 $3�f'lZg C-57Contractor EZ5t1?AWIA16 Address 2 Z 0 -E-141,7---5:T City UOp-DL-AWP Lic TA2934 Phone s!o 66K A4eZ¢ Consuttant/SubCntr �4CC-014 Address A/D( 05650T1L✓57 � lt"O��8ity �i4Y(�� Lic fob Phone y/d-i�7Q�4S%0�( Billable Party At C-0 1"'t AddressCJ��1BSTtfl2� SM L9`C�itppy_I-'uu—"> Zip 6� Phone s�a�7� �s�g GIS Coordinates:X Ala? �� Y !,L -far..3� CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLJBORING(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 0,e Air Sparge.Ozone)❑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: D TRUCTION METHOD: CHECK ALL THAT APPL #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF JO _INCHES TO DEPTH OF -2-0 FT WELL IDs: 14 0-1 . MW`.1 . iM 0 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS EF4 ❑EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS []HOSE ❑PIPE ❑MUSHROOM CAP AT L?