Laserfiche WebLink
PQ�Iy • $AN JOAQUIN COUNTYRICEIVEEyLE COPY <br /> r `t ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> < <br /> 600 East Main Street, Stockton, CA 95202-3029In'N 19 20 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:www.s' OV.Or - <br /> WELL & BORING PERMIT APP LI I $ALHEALTH <br /> VICES �y <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND EMEDMI'Vi4-9 2-61 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV < <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application�'I h LTH <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep ft $ <br /> Site Location !!!. ;- Cross Street +• _ city ,aMeIi zip S / APN <br /> Property So., 1oa&w... C.--.I - <br /> Owner AS/ L.a.4s 7 Address /F/n Fazf (aa>c(>'� /1te. City Zip 5570f Phone eA0 09'69--306�o <br /> C-57 ContractorP<e<•'s,z+� ��%/,y.re_ Address 176.r (r,rr..a... ja• City 5A<4-/,P- Lie 363?7 Phone (2o;)ei�b-saee*Z <br /> Consultant/Sub Cntr 1-k, 5.e 6«1p. Address 91014 woe 4 9 City Lie — Phone Cf3o)272-`hoa <br /> ¢ 14 City . Zip "Y9 Phone& 171-VuBillable Party ace � / d <br /> GIS Coordinates:X go <br /> —I zl-373 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL ❑PVC D OTHER <br /> _D SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _D SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION('a Air Searoe Ozone)❑HAND AUGER GROUT SPECIFICATIONS r <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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 /> LjL4 OF WACL(S)TO BE PpE TROYED CAier'/ec( 1 [M OVER-BORE DIAMETER OF INCHES TO DEPTH OF/W Fl <br /> WELL IDs: , /a/F GlIT A+%Ao( Gell ®PRESSURE GROUTTODEPTHOF /'Of 40')- FT BELOW SURFACE <br /> GROUT SPECIFICATION ®EXPLOSIVES FROM /T TO /LO FT BELOW SURFACE <br /> TREMIE TYPE TO E USED:�]AUGERS ❑ HOSE [�] PIPE ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <br /> COMMENTS / <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMITISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certiftr that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a gliicable California Laws. <br /> Signed /v Title/Company Sfa/;�' Sc.e•+7:`rT� j,` ,« G,�u� Z'�. 4 <br /> Print Name 14141e, 91—r Date /�/�lo i2. (1�� <br /> DEPARTMENT USE ONLY / /_ , <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS �O 7// G(� (,.E� �. L� <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE I —/-D/— 12- 5 EA LMO <br /> GROUT INSPECTION BY IL; >p ..•..•:`�7• 7 7 FINAL INSPECTION BY "#XIA _ _ DATE •10-1L <br /> J <br /> DESTRUCTION INSPECTION BY • �10A - DATE 2`10. 11 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO <br /> REQUEST PR# <br /> # INVOICE <br /> 2RO2, $125X l 2 P3 �� SR#b y283 <br /> (3500) <br /> zoo <br /> C-57 WC WAIVER C57 LETTER,OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FILE COPY � '�°/�' <br />