WORK PLANS - Laserfiche WebLink

Home Browse Search

SA N -tJ O AQ U I N Environmental Health Department COUNTY Greatness grows herd, SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is madein compliance with San Joaquin ounty Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address \ `, �� / I/�G (� City/State/Zip Phone 1 Cross Street APN 'v Property Owner* Phone — Address City/State/Zip Ll(j OT1373 C�// C-57 Contractor S 11 vV- ! License" . II� Phone ((�7 3� j Address 3 + City/state/Zip V4:0 Cr �� yZ / Consultant/Sub-Contractor , v 0 License# /Phone Address? �U �+ City/State/Zip C CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ❑ SOIL BORING ❑ PUSH POINT(GP/CPT) CONDUCTOR CASING ❑Yes ❑No Boring Die: Casing Dia: Casing Depth: ❑ INJECTION(Air soarge.Ozone) ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Yes ❑No (Note:Maximum Freefall Depth is 30 Ft) WELL/SOIL BORING IDs GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) wl l!( #WELLS TO BE DESTROYED 2 5C;I�w� lD (�OVER-BORE DIAMETER of inches to depth of feet WELL IDs AW-I 5 5i1f I ❑PRESSURE GROUT To depth of feet below surface :EF0'661'q'1 GROUT SPECIFICATI NS (Qc Wu ❑EXPLOSIVES From to feet below sur TREMIE TYPE TO BE USED N AUGERS ❑HOSE PIPE fD MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet COMMENTS: l hereby certify that 1 am authorized to complete this application and that the work will be done In accordance with �1n gain County Ordinance Codes and Standards,and all other applicable California laws.//�� Signed Z Title/Company S t/7>!415 �N V//y✓J 4wwyAfe Print Name Cj vt� Date DEPARTMENT USE ONLY Application Accepted By: oy4jdrr"" Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facili /Site Information FA Name (��,( . r1 $p,n+¢ FA Address .(A fe ,r„� �a,,1 FA# d V 23 L I PR# vyy p(e�0 FA PE (e WP Reviewed By L �X Work Plan Date Al I w I /p ❑C-57 1�57 Authorization for Other to Sign Permit orkets Comp Ell Workers Comp Waiver ❑Encroachment Permit ❑Access Agreement [I Lead Agency Approval/ 11 FR COMMENTS/CONDITIONS: /VW jr ypg/le)j, Copxj it eqs,�-0A 6e 'dl-jle WP TYPE PE SC FEE INFO JAMT REmiTTED1 CHECK#I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit Loo-Z 313 $152x 6', y 76o•no of Se!jz I .AOG-1t , 13 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application '^'P 2403 si,3 JI,kS,tx 3 6/-"S-&-uel y FlZ L-,s y'z��f Sdzeo S-6 ,S-37