Laserfiche WebLink
A <br /> • • FILE COPY <br /> Ps.'try SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> N; <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 r s6�EkW03N <br /> •,. Telephone: (209)468.3147 Fax.•(209) 468-3433 Web:WWW.SfaOV.OrDfehd UNIT IV <br /> ENVIRONMENTAL HEALTH <br /> WELL & BORING PERMIT APPLICATION PERMITISERVICES <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 to construct and/or Install the work described. This application Is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmenta <br /> l <br /> .Health Department. I <br /> Site Location It�t9 aeojjo a �� Cross Street V•�o^ Iv•-� t, City/State jy�,f`"ZipLl TIY) APN <br /> Propertyt7..t.- S k SSO <br /> Owner t`5 T V'evt .�"I1 Address s SU Er"cLL'L.- kit..,�, City/State Scus�-Zip DtqS$3 Phoned iZS}395-('j6'S <br /> C•57 Contractor 11�V.1 N) Address-i4Clo uAt Cr,e.V Or rCI[�y}/,States- x tov)jy�ic'1ZJhC4 Phone(Z.S)46ft 7'T00 <br /> Consultant(Sub Cntr YEN-t:r�y_ Address ZrA1 bvz1�-Ni kav/State Shzk grL, is Phone CILi') fI41-111ES' <br /> Billable Party H Address " City/state - Zip Phone � <br /> GIS Coordinates:X 3 T. Tl i$ Y-17_1.29S-d <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> O NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> 0 SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs {{ <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> pp <br /> _PrJ10NTTOR1INcr� ❑HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS E3 MULTI{FUEL WELL CASING DIP: <br /> _0 EXTRACTION:Vapor!Water 0 HAMMER/ORI���fff[����1,p'�1tI�lY, CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY'`r ' DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I]AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING' 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION 0.s.NrSoama.Owns 0HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR Cl STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia:_Casing Depth:_Boring Me: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD•(CHECK ALL THAT APPLY1 <br /> _a_#OF WELL(S)TO BE DESTROYED VER-BORE DIAMETEROF INCHES TO DEPTH OF FT <br /> WELL IDs: _ w1-S W-6 TW- - TW-10 PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFlCATI NS f CAJAeA. EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:LIAUGERS ❑HOSE PIPE 0 MUSHROOM CAP AT(�3 FT) FT BELOW SURFACE <br /> COMMENTS ilTruuAL4 'C-VifGVf:(4 LC. �II/1�. P-OL- L'GSt d1o.0 <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulation9/,and all a Itcabie California laws. p <br /> Signed CI, r t ....._/-�.�- Title/Company SA LJO �z`�FEflt�wa� <br /> Print Name V Date 1I'10 11-3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS9 Li (-AL-I9 L66-0 / / t4A1TF6V <br /> WORK PLAN DATED UCru'ST IS ZUl3 <br /> APPLICATION ACCEPTED BY J-LO EA 16 <br /> GROUT INSPECTION BY FINAL INSPECTION DATE l U <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 RO# INVOICE <br /> REQUEST PR# <br /> 2�oZ $125X 7 'd �a U 8 Ctor.,DrE l0 l y3 sR# <br /> 2.q0� 375- RO# <br /> 3500 <br /> 29 # <br /> 2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC /` <br /> EHD 29-01 5109/12 WELL PERMIT APP <br /> I <br /> I <br />