Laserfiche WebLink
/ w <br /> "• SAN JOAQUIN COUNTY <br /> :. zs ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 SITE MITIGATION <br /> a Telephone:(209)468-3454 Fax(209)468-3433 Web:www.siaov.ora/ehd UNIT IV <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 /> Site Location ZOO pj.WM,Ney flµCross Street 4'Jr�$h1D �Yl City 5N-bf K.-1I»,n zip q5,z )s APN 15`1—D7tr-10 <br /> Property b \ 1.k: <br /> owner SUX C,,'ra-'•:cL1 Vy Address \3S\5 al rr Tt. City CN,-YNo Zip 'UZ-I'A Phone '; -�S7- 3 <br /> Address D.0-57 Contractor a City Uc LA35%'!, Phone q_L-.713 <br /> r <br /> ConsultanUSub Cntr Address IeDS - City Uc Phone <br /> Billable Party �nati Address 1�DCi .3T .5k. City r.'.r. Zip 2D Phone �zD- - \LQ <br /> GIS Coordinates:X 121" 1141 I" y 3°1o5al-3Y <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW W ELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs 1MW- S .i 1hW <br /> OTHER IDs <br /> TYPE 8#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 9 MMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE -�E O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:�n• <br /> _I7 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS Sa,- AD TYPE OF CASING: ❑STEEL 16 PVC 0 OTHER <br /> _CI SOIL VAPOR PROBE AMUD ROTARY DEPTH OF GROUT SEAL I'll TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE J9 PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:KYes ❑No(MAXIMUM FREE FALL DEPTH Is 30 FT) <br /> _0 INJECTION(Le.Nr Soame.Oz...1❑HAND AUGER GROUT SPECIFICATIONS12' <br /> —❑OTHER: ❑OTHER: APPROX.BORING DEPTH 1--�9 1 13 5' (BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> \ .l � <br /> CONDUCTOR CASING Id No,[3 Yes:Casing Dia: t Casing Depth:_ Boring Dia:_ <br /> COMMENTS: ,!\\ �l�I ywe% Sc�iirc e,l , ;:vti -1A ��b z�.. A. -;0 <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHME T PERMITS J <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 <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and a�ppllcapyla a�lliomla Laws. •.7 <br /> Signed � k-c�-�1%'�'\ Title/Company TCD j et.� 4^'laws�,arY 17wJ r,ti <br /> Print Name —D Dale -IFS- Z➢ I Z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS /$U N, <br /> WORK PLAN DATED -2 -12 <br /> APPLICATION ACCEPTED BY a*K"'VL DATEISSUED AREA �`c( <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> )MOI $125, ccyrr art) 6-fj-tZ SR#SRWIaS/5` <br /> 2403 37 g42uy{� RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 y WC r. WAIVER rZ(,— C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS <br />