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4Ur" SAN JOAQUIN COUNTY FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT LOP •' '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 RE N c�• ::•�;:P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or /ehd fl <<Foa Iq q WELL & BORING PERMIT APPLICATION JUL 2 5 2014 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND R TTIlON NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MIT/SE VICEALT�9 PERMIT/SERIIICEg 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&� �- All P-001 1 tGYCross Street �l�l s �dci�r�? r'rC Cit /State q�t�Zi Property�A �1- AA Y A to 5t5 APN 2 0 -1�0 -( I Owner ,�"Aj I-rA //�°'r' Address (22� �f, OR�Qr Ar P'—? -9PI[ a City/State �A/�(� Zi �3� Phone Del' X523'yS�'� C-57 Contractor L1a.5cade �rIlliU,; Address ,3000 Z,ud u-�4 SG'reef City/Sfate�f4"1p'� Lic4 //O Phone 9/6 Consultant1Sub Cntr ffla IMC• Address 9 z 3Y/NE�I�'�QUAY City/Statet Lic Pty Phone-4U-4-5a3 -1010 Billable Party -AAJ Address City/State Zip Phone GIS Coordinates:X 37,7 Y —/a/, ,2<n/,5� CONSTRUCTION WORK TO BE PERFORMED: .❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑ SOIL BORING IDs 19-WELL IDs /j1U-21 MW- 'aR f MW-23 r1hW_02�t ❑ OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS '�—Eu"MONITORING k-I OLLOW STEM DIA.OF BOREHOLE 13�c ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: r —El EXTRACTION:Vapor/Water I_]HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: El STEEL i.,�PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAS-22 32 3 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE NIPIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:q-Yes ❑No( UM FREE FALL DEPTH IS 30 FT) /Uo 96-' s0rrL _❑ INJECTION(i.e.Air Sparge Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 19;s,'575,—'151 20" OLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING jl�'No ElYes:Casing Dia: Casing Depth' Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L?