Laserfiche WebLink
t IN• p SAN JOAQUIN COUNTY MAY b 0 ?_015 <br /> —.m- ENWRONMENTAL HEALTH ®EPARTME6� LOP <br /> dr a �UII ONMENI T 4MIGATION <br /> >: I 1968 Hazelton Avenue, Stockton, CA 95205-6232 PEI ;t,S(T/gEI�T'ICEeINIT Ib <br /> -...- a Telephone:(209)460-3167 Fax:(209)469-3433 Web: 1rrt�teJ.�.IDoy.g feh <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND DORINGS 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 app:cation is meds In compliance with San <br /> Joaquin County Dove'opmenf Title,Chapter 9-1115.3,and the Standards of the Sen Joaquin County Environmental Health Department. <br /> Site Location 411 W.Dr.MLK Jr.Blvd_ Cross Street _S Van Buren City/State Stockton,CA Yio 95206_ APN_147-076.06_ <br /> Property <br /> Owner_Wllam Halvorson Address 10040 Davis Road CRylState Stockton,Cute Yip j5M Phone <br /> C-57 Contractor _National EWP Address City/Slate 'k gi 3y4; More .51 r1-23G+-/r.2.pZ <br /> ConsullanVSub Cntr Stanta®® Address 3017 Kilgore Rd,Ste 100_ City/Stale_Ranctw Cordova,CA Lie Piton® 916.384A766 <br /> Bi6abde Party,_Stantec Address 3017 Kilgore Rd,Ste 100_,_, Chy/Stale _Rancho Cordova.CA Pio 95670 Phone 916354.0706 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLISCRING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs - <br /> ❑WELL IDs <br /> ❑OTHER to- <br /> TYPE&L OF WELLIBORBNG INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING O HOLLOW STELA DIA OF BOREHOLE _ ❑MULTIPLE CASINGS O MULTILEVEL WELL CASING OR <br /> _O EXTRACTION:Vapor/Water O HAMMER/DRI/EN CASING THICKNESS TYPE OF CASING ❑STEEL 0 PVC ❑ OTHER <br /> —L7 SOIL VAPOR PROBE O MUD ROTARY DEPTH OF GROUT SEAL TREFAIE TYPE TO BE USED: ❑AUGERS O HOSE ❑PIPE <br /> _O SOIL BORING 0 PUSH POINT(GP/CFT) GROUT SEAL PUMPED'®Yea ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION aA4L1ama_OMW El HAND AUGER GROUT SPECIFICATIONS <br /> _O OTHER ❑OTHER: ®®APPROX.BORING DEPTH O BOLTED TRAFFIC BOX OR O STOVE PIPE <br /> CONDUCTOR CAS NG❑No O Yes Crowns Dia: Casing Depth® Boring Ola.® <br /> t:oMMENT6•-�SL'� Cit_�tiCil'lkc-� ��u' <br /> NOPE: OFFSITE WELLS &SCRINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMrrs <br /> D STRUCTION WORK RERFg-Rh92: DE§TRUCTIQUOD: HF TAPPLY) <br /> FOFWELLjS)TOBE DESTROYED DOVER-BORE DIAMETER OF _� CiCHESTDDEPTH OF•72 SFr <br /> WELL IDs A nj i& `-/'o , ✓I SP1 Lia-/ Q'�RESSURE GROUT TO DEPTH OF ?i 7• S FT BELOW SURFACE <br /> GROUT SPECIFICATIONS 1/S C' 4'4��V3F't?�— ❑EXPLOSIVES FROM--------TO—FT BELOW SURFACE <br /> TREWS TYPE TO BE USED!❑AUGERS ❑HOSE PIPE ❑N¢USHRQOAq CAP AT L3 FTSELOW SURFACE <br /> COIIAMENTS• G'v�7 �-LFvtC � (( .� � { += H-f'f li Irl vL-J 27 r C�:Z'UY <br /> a ICORK��I--PIG DAYS) NI OTICS REQU9lr FU(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby Conley thae I hava prepared Bits apPlleadon and that the work will be done in accordance with San Joaquin County Ordlnanees,Rules and <br /> Regulations,and all applicable California laws. d _ �� <br /> Synod - � TitkilCompany <br /> Print Nam - I Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE•sn E ADDRESS 519';9 DO , Gln C"I L-PA LJ C.—, <br /> WORK PLAN DATED Tl k&L 21 <br /> APPLICATION ACCEPTED BY DATE IS UC'D S" �S AR <br /> GROUT INSPECTION BY s!� FINAL INSPE TIO BY ' ATE /3 <br /> DESTRUCTION INSPECT( Y DATE 7 7 <br /> COMMENTSICONDITION .5� <br /> ACCOUNTING ONLY. AID B FAC Y <br /> PE CODES FEE INFO AMY REMITTED CHECK 0 RECV'D BY DATE SERVICE RO S INVOICE <br /> REQUEST PR <br /> RD 0 <br /> (3 0 <br /> PRD S36L1s� <br /> C•57 (Arc WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FHn 7A 1 7"'1" WFII PFRMITAPP <br />