Laserfiche WebLink
e <br /> q.P4V•In• c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> a<<.,•;:� tr Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siaov.org/ehd <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 DevelopmentTitle.Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location aVD N- We � eY C Cross Street City S�btlt3on Zip SZ)S APN I .3 ".3I D:j <br /> Property �� � y <br /> Owner r e� Address 5 w city�llC_Zip Zg21Phone D4-4SZ <br /> C-57Contractor r c Address So city Lic 48a.5 Phone 32-5-313 \9a <br /> Consultant/Sub Cntr �a _ Address l YA City 'cc:N,.:, s Lic �.,�'�1 Phone <br /> Billable Party .�e�__� Address �b5 Y3y _ Cily rY�c,:�.�z�S ZIPPhona - 4 1'-"7��'� <br /> GIS Coordinates:X �2�D Ol W Y 3� S3 3 -'N <br /> C NSTRUCTION WORK TO BE PERFORMED• <br /> NEW WELIJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs <br /> DS WELL IDs NA-- tu <br /> ❑OTHER IDs <br /> TYPt�E 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'L_% ❑HOLLOW STEM DIA OF BOREHOLE -'� ❑,`MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 [X. <br /> _ EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS — W 4ID TYPE OF CASING: O STEEL 134 PVC 0 OTHER <br /> _O SOIL VAPOR PROBE aMUD ROTARY DEPTH OF GROUT SEAL Nj'2'1 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE PIPE <br /> _O SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:,P!.Yes 0 No(MAXIMUM FREE FALL DEPTH IS 3D FT) \ <br /> _O INJECTION Ile nh wares.owns)O HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH <br /> '''' O BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> r, r/ ` CONDUCTOR CASING 9LN.❑Yes:Casing DIS:_Cesing Depth:_Boring Dia:� <br /> COMMENTS: )A)2�1 Cbi�� ` 7 - eN1s \�.. �c�.r �ir�«t' - h'Y�E Wt'l.f`a, � �. i ,r�e 135 <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS GREEMENTS OR ENCROACHMENT PERMITS �S <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAPPLY) <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 I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and/allp Icabi� al Fomia L s. \ �n'^s j <br /> Signed rr\ Title/Companyle�j e,✓ / Duc'IP <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS ! �^ -c ltni .•-s /y'p U Sra,P 4/3/2 <br /> WORK PLAN DATED 9-l2 <br /> APPLICATION ACCEPTED BY ^ . yc,*Ku r+'1 DATE ISSUED G-ZI- IZ AREA /G-tq INSPECTION BY 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# RECV'D BY DATE REQUEST SERVICE RPRO## INVOICE <br /> // <br /> 290 l S125x 2 T crk 649-19- SR#(,0 Sl <br /> 240?� '2'753G) oqd' RD# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 v WC_)WAIVER .vda- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS <br />