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LOP <br />SITE MITIGATION <br />UNIT IV <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 />Joa uln County Development Title, Chapter 9-115.3, and the Standards of the San Joaquin County Environmental Health Department. <br />,BY Cy C�i✓ojilG �tlF/�1? / SFo Alcv ./ A 7 <br />Site Location �1/ AF '0WrC> Cross Street '9V City ���/ Zip 276 37/ APN <br />Property /�/ /97'�e LSC / U� ��.ZOS� /5ef 9�01P %��3 <br />Owner C �c X35 Adddress 6 L ��,,✓� CityJ Zip /Phone �i <br />C-57 Contractor X6r AWC <��Pbedress / O 4A_ W65 Cit /%�f%R/�/�EZLic��S/6JPhon�A� 3! 3 sa W <br />Consultant/ / Address//01/r Al ,BAR y ,f�E�i�1ic% hon `�-w p�� <br />Billable Party_ ,� Address ��/O C %f%i/d^City .i%6sti 4A1Zilp S � Phon / 6/ 1p 3CJ�b <br />GIS Coordinates: X �� .�5�%Y oaP41'!,(eA'V-1 <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />SOIL BORING IDs <br />WELL IDs 0 <br />❑ OTHER IDs <br />TYPE & # OF WELUBORING INSTALLATION TYPE <br />MONITORING HOLLOW STEM <br />_❑ EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN <br />_❑ SOIL VAPOR PROBE (1 MUD ROTARY <br />_❑ SOIL BORING PUSH POINT (GP/ CPT) <br />_❑ INJECTION (i.e .Air Sparge, Ozone) ❑ HAND AUGER <br />_❑ OTHER: <br />❑ OTHER: <br />CONSTRUCTION SPECIFICATIONS /f !i // <br />DIA. OF BOREHOLE /V17 Al [I MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: � ! <br />CASING THICKNESS )OW � Sl(G �PE OF CASING: ElSTEE VC ❑ OTHER <br />DEPTH OF GROUT SEAL 2 FT- TREMIE TYPE TO BE USED: UGERS ❑ HOSE ❑ PIPE <br />GROUT SEAL PUMPED <br />Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH IUV / / ❑ BOLTED TRAFFIC BOX OR)RISTOVE PIPE <br />CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />C0MMENTS: /,7 0.7 eAW'j C <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /># OF WELL(S)TO EIE DESTROY D ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br />WELL IDs: v'✓ _/ _10 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />GROUT SPECIFICATIONS ,P��/ EXPLOSIVES FROM TO FT BELOW SURFACE <br />TREMIE TYPE TO BE USED: AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L? <br />