Laserfiche WebLink
SAN JOAQUIN COUNTY � a R I U N N <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> . , • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> T <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.s' ov.or l C-� <br /> WELL & BORING PERMIT APPLICATION G <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATim 18 '2014 <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 iENVX*NMWAkHE1A0H <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health DepartrrP�MIT/SERVICES <br /> Site Location ��S- IC�vCrro sStreet Ci-sLw.� City/State`7faCKPN Zip q5✓�6 APN 1y- - a9a-ll <br /> Owner l of°0.-nr� �{�t n�traJ �'tProperty ress .�IJ� Ta��eG �!/L2. City/state�jo <br /> /l' *KTW Zip 95�CPhone')°1'4W-3UJ5— <br /> C-57 Contractor (.� fi�/� Address .3600�aJK�I 5ft9G'1 city/state`.�idgte"Lic ",?//O Phone 9/6-4638-1169 <br /> Consultant/Sub Cntr C7,41>IDA/d- Address Cit y/5tate�i�tnT Lic11� 6�Phone <br /> Billable Party -j*M&- Address City/State Zip Phone <br /> GIS Coordinates:X J "� , ° r z a LA-rt 3-7,A 4:5416b* LoPb: 121,Z g 73�t 3° <br /> zP�Fso <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑�rSOIL BORING IDs _ <br /> ey WELL IDs .MW Y ; /ti(LfT� <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS p <br /> 1•�MONITORING HOLLOW STEM DIA.OF BOREHOLE S" <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z <br /> _[]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS 5r-ti L40 TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ElMUD ROTARY DEPTH OF GROUT SEAL <br /> ,.,/Z f TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE PIPE <br /> _f]SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: la Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) Vc> &uL7vw1,T <br /> /� <br /> ❑INJECTION f e.Air Sparge.Ozonel❑HAND AUGER GROUT SPECIFICATIONS 1�/1 ri .ti 0✓trt"tN� O6-r <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH SO BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING eNNo❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUTTO DEPTHOF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑ PIPE ❑ MUSHROOM CAP ATL3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify tin a preps application nd that the work will be done in accordance with San Joaquin Count Ordinances, Rules and <br /> Regulations,and pplicable alifornia law / 1 <br /> Signed - Title/Company &03ecl' a o5T /7 <br /> Print Name w Date_71ldl-26 y <br /> Q DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS A r'1 a z r01 NdJ .$7'2.K j Q i J r2(7KP0/U <br /> WORK PLAN DATED I1'I 0-Q4114 /R t 2-v /y <br /> APPLICATION ACCEPTED BYJ N�n�wtCl-�c✓Y DATEIISSSUED '�/21-1y AREA /GY <br /> GROUT INSPECTION BY /J/✓G/ ,f/l G� FINAL INSPECTION BY /✓y+G�yrYfs Ak,, 4 DATE g 2< <S <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST I PR# <br /> 90 I $125x SUN 7— , L SR# !U(� <br /> np RO# <br /> n l U 7 (3500 <br /> PR# <br /> (zsoo <br /> C-57k� WC WAIVER tU14- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _,ENCROACHMENT DOC <br /> EHO 29-01 5/09/12 - WFII PFPMIT APP <br />