Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> �!•' .r-err= ••. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: UNC <br /> '9trkotii+� pone: (209) 468-3454 Fax:(209) 468-3433 Web:www.siQ-- °�hd <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 t0 construct and/or install the work described. This application is made in compliance with San <br /> Joaquin{YCounty Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location rd•SO S. CtAAAatra, Cross Street �.. orl•l., <br /> Property City sfm lk4oh Zip 15206 APN NA <br /> Owner;4: e'f <h ci (j, Address <br /> C-57 Contractor <br /> tQclJaro! Aqy".ff prnaolo cityslxk�o,t ZiP_9s2ce- Phone <br /> Address I"0dS2y 336 -. <br /> ConSutanVSub Cntrtt11v12La�we, - CitYgtoJrS�e. Lic 1CO <br /> u.YsY 15D CI Phone <br /> ��_ Address 2235 MCrcOv�� ty�t�lla koia Lic .J(h Phone 7y71d <br /> Billable Party i✓IZIa•I, 1 I Address 2Tis thterc r.,- dE 4 <br /> GIS Coordinates:X 3 6 y IZI b��346 —='�--� city •Q� Zipe 407 phony-x2T1.sz3--ig,,, <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®'NEW <br /> E]SOIL WELL/BBORINGORING(IDs CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> RrWELLIDsIMW- <br /> [I OTHER IC <br /> TYPE&#OF WELLIBORING INSTALLATION CONSTRUCTION SPECIFICATIONS <br /> •9 9 MONITORING HOLLOW STEM /r <br /> �' DIA.OF BOREHOLE �El MULTIPLE CASINGS MULTI- d <br /> _I7 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN N LEVEL WELL CASING DIA: Z <br /> _.O SOIL VAPOR PROBE CASING THICKNESS AL LIL) TYPE OF CASING: STEEL PVC ❑ OTHER <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL ^'`.L7/ TREMIE TYPE TO BE USED: ❑AUGERS <br /> _�SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:99 Yes ❑No(MAXIM/UM FREE FALL DEPTH IS 30 FT) HOSE.�PIPE <br /> _p INJECTION neAls O=ne)❑HAND AUGER GROUT SPECIFICATION <br /> S1YPTt� Llaa�tCew�c�� r 3ejp <br /> _0 OTHER: ❑OTHER: 6�rr�+�I b� w (,t <br /> ,,LL .�II APPROX.BORING DEPTH _� [fjBOLTED TRAFFIC BOX OR _o- <br /> COMMENTS' (O(,fwlw.p ' r CONDUCTOR�ASIjJG 8 No 0 Yes:Casin Dia: ❑STOVE PIPE <br /> �`^��- t° 6'"." <br /> F 0 5•�f,�rNiq Casing Depfh: Boring Dia: <br /> NOTE: OFFSITE WELLS JRMED:BORI <br /> DESTlx­--w—BE PERFONGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> RUCTION WOR <br /> —,OF VJELL(S)70 BE DESTROYED DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF <br /> GROUTS ❑PRESSURE GROUT TO DEPTH OF FT <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑EXPLOSIVES FROM FT BELOW SURFACE <br /> COMMENTS ❑HOSE ❑PIPE ❑MUSHROOM CAP qT L3 FT) TO FT BELOW SURFACE <br /> FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PER ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby cert�'J: <br /> a prepay d this application and that the work Will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulationsd ppl able C Ilfornia laws. <br /> Signed nnnn <br /> Print Nfe � po„r ok,K. Title/Company i� �ize�oai <br /> Date shy <br /> SITE MAP IN UNIT IV FILE-SITE ADD ESSt2-O S. <br /> DEPARTMENT USE ONLY <br /> C)At, �,. I Gr-.• <br /> WORK PLAN DATED_ $ I I�•I I ; <br /> APPLICATION ACCEPTED BY (Airw <br /> GROUT INSPECTION BY ( DATE ISSUED <br /> �„t 11-� Icy(I/ AREA <br /> eFINAL INSPECTION BY —y-� <br /> DESTRUCTION INSPECTION BY �-*-- DATE{ <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODESFEE INFO AMT REMITTED CHECK# FAC# <br /> q O I RECV'D BY DATE SERVICE RO# <br /> OL 1 $122x Z `Wzt;V-00 ( 6R <br /> ( tZ REQUEST PR# INVOICE <br /> RO# <br /> 3500 <br /> PR# <br /> C-57 WC WAIVER 2900 <br /> EHD 29-ot o7j2S/to C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCROACHMENT DOC <br /> WELL PERMIT APP <br />