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s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP .a �. ` SITE MITIGATION •=•� '• 600 East Main Street, Stockton, CA 95202-3029 UNIT IV 4�7FQ -.•;P Telephone: {209) 468-3454 Fax: {209) 488-3433 Web:wvwrsicrov.orq/eh WELL & 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 andlor 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 1661 E-ka:E.-- Avv Cross Street W W..I.of S*_ City fpj. Zip !;i C APN 1,?"7 0Z031 Property Owner k-fdp m Md rcA m Address PC7�io�r S o �^ City 5,(g2 rfp,d ]Y Zip I' Phone C-57 Contractor cI Address 3632 Or ec Cw,-dr. City 3$tID Phone lie, 6u. '1)6f, ConsultantlS ub Cntr- A fI c A bar S Address q.17b G It nr City Fo i c ow Lie Phone-ILL. '1€S- 2a74 Billable Party --eje. C4,4rf Address City Zip Phone GIS Coordinates:X Y 1 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELIJBORING(CPT,GEOPROBE.HYOROPUNCH,HAND.AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDS ❑OTHER IDs TYPE&#OF WELLJBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DtA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water [3 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _Q INJECTION{i p akSparue.Ozer* ❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: (/w-f {R__ yLw_3 0EATRUCTI ON METHOD.,ICHECK ALL THAT APPLY) #OF WELLS)TO HE DESTROYED Sd L SP-I AA314: SP-2 A/e/c SP-2 19 OVER-BORE DIAMETER OF��_INC14ES TO DEPTH OF�i SFT WELL IDs: ti-I ryr,- mu-6 s" M u-ro r.- IMI.,r-1 fkg PRESSURE GROUT TO DEPTH OF a 13.1 FT BELOW SURFACE GROUT SPECIFICATIONSr«,,{ rer a, _ L1 SE FROM TO FT BELOW SURFACE TREMI E TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT 1?