FIELD DOCUMENTS_FILE 1 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY Viso' LOP ENVIRONMENTAL E T E SITE MITIGATION pM." 600 EastI in Street, Stockton, CSA 95202-3029 UNIT IV ceFTa,' Telephone., 468-3464 Fax"(209)468-3433 Web: .S. o ,Crr Ii APPLICATIONWELL & BORING PERMIT FAIR WELLS ANIS BORINGS USED FORCONTAMINANT INANT INVESTIGATIONS AND REMEDIATION N N_ON-REFUNDA13LE PERMIT EXPIRES.1YEAR FRQM C ATF LSS EQ Application is hereby made to San Joaquin aunty for a permit to construct and/or install the work described, This application is made in compliance with Scan Joaquin County Development ent Title,Chapter 01.1115:3,and the Standards of the San Joaquin County Environmental nmental Health,Department. I ; . ,vixoN s . Site Location5`000S. Cross Street $ � _ City 'C" Zip _ I�l'h! # . Property S " AIRPORT WAS' owner AA J° AaV1 C VNT Address Clty I1 .Zip tt Plane t clI PART" C-5 Contractor T Address City A L c Phone_IL3� I ClonsultantlSult Cntr ftA l°8 �. Address P-0. aOx 183S3 City I L.ie. 5 Phone E- ' S Billable Darty RA M A 6*I I-N V. Address F4. X 183sli City Zip It Plano j S 3, GIS Coordinates:X 31 I C t� 44 3 LAT/L CONSTRUCTION WORK TO SF PERFORMED: nINEW t ELLIS RllalC_(CPT,GE6W6O i,9~IYLT�C?PCINCH,HAND-AUGER,OTHER) SOIL,BORING IDs �I e�CT`l FIR Pms SOS PE A# F WEL.UBORI G lid»TTL LA"IQN TYPE N sT UOTIQN SPECIFICATIONS IFICATIONS 0 MONITORING 0 HOLLOW STEM DIA,OF€OR HOLE 0 MULTIPLE CASINGS ING 0 MULTkLEVEL WELL CASING DIA- _0 IIA,__,0 EXTRACTIa a Vaapor/Waater 0 H.AMMERIDRIVEN CASING THICKNESS Ist A TYRE OF CASING: I_l STEEL 0 PVC; C1 OTHER __,C3`OIL VAPOR PRO MUD ROTARY DEPTH OF GROUT SEAL _TREWE TYPE TO 6E USED 0 AUGERS 0 HO SE qua r�iPF _O SOIL BORING EirrIU H POINT(GPI CPT) GROUT SEAL PUMPEDYes YNo(MAXIMUM FREE FALL DEPTH!S art FT) [I INJECTION e A r� arae._ zn E3 HAND AUGER__,_GROUT SPECIFICATIONS_tULA t CKMENt____ OTHER OTHER, APPROX,BOWNG DEPTH F __ C1 BOLTED TRAFFiC BOX OR 0 STOVE PIPE CONDUCTOR CASING G Cs(w Li Y.$;Casing Glia. Casing Depth:__ _ Boring Dia:_ COMMENT& 6 S t L VA 0 M S A M P L !#0 N S Wt$ Kj_ _+Cjj ?t _ 1FA OTE; OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS ENCROACHMENT PFR IT'S DESTRUCTION t RE TO BE PERFORMED- t� RLICT 3l l T�iC�IT. cr�E KALI TatAT_APPLY) #.OF WELL(S)TO BE DESTROYED 0 OVER-BORE MAMETFR OF-INCHESTO DEPTH OF FT Ll. €LAS: [ PRESSURE GROUT TO DEPTH OF FTBELOW SURFACE GROUT SPECIFICATION _ �_ [ EXPLOSIVES FRONT _T0___FT BELOWSURFACE TREMIE TYPE;TO BE USED,[ AUGERS 0 HOSE [3 PIPE [:I MUSHROOM CAP AT(: ET) FT'SELOWSURFACE COMMENTS S WORKING,DAYS NOTICE REQUIRED'(AFTER PERMIT IT ISS AI ) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be dorsa in accordance with Sara Joaquin County Ordinances, Rules and Regulations,and ap l le C 'forroa lavasPRINCIPAL 1,p 8 T- ;p e A 1 i+s,;¥C t r r ,,)n A A q`' A PrInt NameS I A fr -__ _._.mate ' II USE ONLY SITE MAP IN UNIT IV FILE_SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED AREA GROUT'INSPECTION SY FINAL INSPECT ON R f _ _DATE m mF STRUCTiON INSPECTION BY DATE_, CO M NTSICONDITIONS. _ AaCCOUNTiNG ONLY: AID# FAC# _ R DATE INVOICE It HJT" .PIS RS t} S FES VNFC0 T REMITTED CHECK# f� G D 5 _Tr _,..._._ .....2, .� RCS# .-_ 66 00 3500 C-57 +IC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT � ENC ROAC14MENT"DOC EftDTP_CT FiT2 l~Id WELLPOE N_4irTF(