Laserfiche WebLink
aPA�lh.. SAN JOAQUIN COUNTY 011 RECElykq COPYAPR 10 2012 <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> X18 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENTR11ATION <br /> p Op�� W <br /> ga?;r. Telephone: (209) 468-3454 Fax: (209)468-3433 Web:www.siao)P.I;FW8E <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 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 Environmental Health Department. <br /> 20963 South Brennan Avenue <br /> Site Location Cross Street Williams Road City Escalon Zip95320 APN 247-04-002 <br /> Property <br /> Owner Nelson Land and Cattle LLC Address City Zip Phone <br /> C-57Contractor ECA Drilling Address 20 Box 52 Cit, Tahoe City Lic 695970 Phone 831-662-8178 <br /> ConsultanUSub Cntr ABT Consultants Address 2500 Camino Diablo Cit, Walnut Creek Lic 654919 Phone 925-746-6000 <br /> Billable Party AEI Consultants Address 2500 Camino Diablo Cit, Walnut Creek Zip 94597 Phone 925-746-6000 <br /> GIS Coordinates:X37-46'39.85" N Y 121°01'09.08" W O <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOILBORINGIDs SB-1 and SB-2 W <br /> Cl WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING D HOLLOW STEM DIA.OF BOREHOLE _ D MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL D PVC ❑ OTHER ..y <br /> _O SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS D HOSE ❑PIPE V' <br /> 2_02 SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:D Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 6) <br /> —D INJECTION(I. Air Soame ozone)❑HAND AUGER GROUT SPECIFICATIONS t <br /> _D OTHER: D OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING D No❑Yes:Casing Dia: Casing DepN: Boring Dia:_ h <br /> COMMENTS: Two borings (SB-1 and SB-2) to 20 feet bgs for soil sampling. Backfill with neat cement grout. <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS 7 <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 GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE (` <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE K <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I h4ye prepared this ipplication and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 1Plicabl alifo Laws. �i /'eO /O1 1/4 <br /> Signed Title/Company HT1- G-I �f ( i 5 <br /> Print Name r ah � Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 109(4-5( 3 S 9120VaN <br /> WORK PLAN DATED P 21 �- Zd f 2 / oG <br /> APPLICATION ACCEPTED BY } fo uu'l DATE IS -I 2 2 <br /> AREA �L <br /> GROUT INSPECTION BY FINAL INSPECTION BY tGA.'.u.n✓t^ DATE 41-164 Z <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DITIONS: <br /> ACCOUNTING ONLY: AID# 7# RECNrD <br /> PE CODES FEE INFO AMT REMITTED DATE SERVICE RO# INVOICE <br /> REQUErrSrT,� PR# <br /> $125 x 2-) SR# (0 (300 <br /> PR# <br /> �3 2900 <br /> C-57 WC (i WAIVER A"'o C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />