Laserfiche WebLink
7-- 74 <br /> 0 <br /> SAN JOAQUIN COUNTY -F1 <br /> 119 LE COPY <br /> .1.4 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-623LZ01SITE MITIGATION2 UNIT IV <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sjqov.or-q/ehd-,, .-' <br /> WELL & BORING PERMIT A P P L I C Alt"10' N'',- <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND iREMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES I 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 is made in compliance with San <br /> Joaquin County Dryp e T'I Ch ter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site l­ocationb� 3-1 <br /> Property, B- 'UTA M.Cross Street b(4JF14b- City/State TKACY,64 Zip �190 j APN 2Z-IS-P-78 <br /> Owner �L '5 oss'wav <br /> - Address ✓;ILD WV>7-r HW1 6,'Y City/StateJ&J�LKQZip 71�q� Phone q5`9-66 <br /> 6jgfCj <br /> C-57 Contractor & b,0-i1,t11VCr Address 95-0 fbk)f, h,4-i Vj� City/State Illy-mi M­Y&ZZ&SPhone 31.3-SSDa <br /> Consultant/Sub Cntr 37)4VV-r-CC, Address 5?-1,4FAf/[;M C,!<,1-4 qq'�- 931 <br /> a:�City/State I Phone <br /> Billable Party S7;4A)I�G Address City/State Zip-21 <br /> J��q Phone <br /> GIS Coordinates:X 7t 2:46LY -I?-(-3Zj 969' <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> E]NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs; <br /> [:1 WELL IDs <br /> El OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _E1 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE _ E:I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS —TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS C1 HOSE 0 PIPE <br /> —0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _[]INJECTION(i.e.Air SDarue.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _[I OTHER: 0 OTHER:-- APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING[I No 0 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 /> W TOF WELLS)TO BE DESTROYED KOVER-BORE DIAMETER OF /0 INCHES TODEPTH OF '2-S FT <br /> LL*1 IDs: 12 -L 7E]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS/;01&/J [:3 EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[I AUqERS [I HOSE RPIPE 13 MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS Rk)-2- 0 A 4.S:v�EL-2 /VfiAf1VZ(* k) L- -TV er &0V- t(LLeA j,,)/ 57KIt ,t6fX5 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h ve pre 0 red this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all plic 71a5mia la�4e <br /> Signed I Title/Company /A)JEJ, SC_141�47751- <br /> Print Name— WAM &&�CA 161�( -5T Date /.3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 7 Ix tR 02 V <br /> WORK PLAN DATED j LkkLi <br /> APPLICATION ACCEPTED BY 4D1T4XW AREA 169 <br /> GROUT INSPECTION BY 0 FINAL INSPECTION By DATE -- <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> $125x oouv I ? SR# <br /> RO# <br /> (3500) <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER LL/4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT /ENCROACHMENT DOC kt.,,74 <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />