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x•, ,.Foy SAN JOAQUIN COUNTY CRIGINAI I '� ENVIRONMENTAL HEALTH DEPARTMENT REGGIN&D 1868 Hazelton Avenue, Stockton, CA 95205-6232 �`�•.- :'� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sigov.ora/ehd UNIT IV 'Ra+� JUL2014 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMNOMENTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 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. 2S� Site Location a; 1Wr Y��'* Cross Street A I �'r°�' City/State .M4� G Zip Q633 3'� APN Property �• n Owner A t; M�uul i (�oti5 Address �t �,,�� 1iS }2'-f 1 City/State l �JIA.S it ©:S7 Phone��5 C-57 Contractor �C-" -O! i' lei Of Address �o RA I -t- fin Si7b�A+ Clty/S ale raofeM4T- L i c 93oo/70 Phone 916- 6 59- 9'Consultant/SubCntr Consultant/Sub CntrCITD, 1, Address ��3s�lEF:C.P-+ICYWAt City/StateS�14&t Licf&*gM Phonek-f- 13'(010 Billable Party _ SlIkA46 Address /5?1 City/State Zip Phone GIS Coordinates: X -? 7496710 Y INVOICE 3.7.-79 Oa9 -la/, ?S3k30 $ 125 x ip CQNSTRUCTION WORK TO BE PERFORMED: > c 0 3 / ! NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ❑1,9011- BORING IDs WELL IDs N O G -/ ❑ OTHER IDs TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS it ��/ L MONITORING �OLLOW STEM r DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL, VC ❑ OTHER ❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEALSA'3.:� TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE PIPE _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED:jdYes ❑ No (MA MUM FREE FALL DEPTH IS 30 F AID B(-�rte/1►1?� _❑ INJECTION (i.e.AirSparge. Ozone) ❑ HAND AUGER spp GROUT SPECIFICATIONS I VT-- ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTHIOS' s _4O 15 BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING ❑es: Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS V r 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?