Laserfiche WebLink
SAN JOAQUIN COUNTY • FILE E CO <br /> .�. P Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-621132 I E MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:wwWsiaov.oriWE <br /> WELL & BORING PERMIT APPLICATION FEB 10 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIOh S AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT <br /> IW �.t�, <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. T is application raw . A q*San <br /> Joaquin County,[]p�vg IFant Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. CES <br /> Site Location �1090D44kcgw i Cross Street S Tu/sw A,v - City/State S-Y"4A Zip 9S1/S APN /o3//ooS <br /> Property 54- Se.}�.,„ Co, - - I, <br /> Owner AV..I L/e.4r Aavf»w A Address /8/O 5csf HG e/�M 4t w_ City/State S/ k Zip 95�205 Phonec205)/f68-?000 <br /> C-57 Contractor Address 950 .ler."e 41, City/State . &,cz!/{Lic 1w.15" Phone r9 ?/7.6302 <br /> Consultant/Sub Cntr Address 1"Caw•{ & ! City/State Gdn�dd_ic_.UL Phone Cir&& X72-1200 <br /> Billable Party ,. Address 911 Hile",�w /L/ `,t City/State /va., c,��Zip W 9y9 Phone t!r~i01177--"/wU <br /> GIS Coordinates:X 37.4 AS Y —(Z/• /07 / <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> "r��"r""uft "BPUNS1 I,I INNS AUGER,ETHER) <br /> ❑SOIL BORN G1Ds <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �, [I MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _I]EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS f,�A TYPE OFCASING: ❑STEEL ❑PVC ❑ OTHER <br /> —0 SOIL VAPOR PROBE ❑/MUD ROTARY DEPTH OF GROUT SEAL " N r TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [PIPE <br /> -L2/SOIL BORING f`PUSH POINT(GP/CPT) GROUT SEAL PUMPED: Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e Alr Svarae.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _I]OTHER: ❑OTHER: APPROX BORING DEPTH /1/O' I]BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING Q(No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALL THATAPPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: [IPRESSURE 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 <br /> COMMENTS E] MUSHROOM CAP A7 i>3 FT) FT BELOW SURFACE <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 a pplicable California laws. <br /> Signed / Title/Company oec-( Sc/r.� <br /> Print Name AGGM e4.o�..,n ale ;Ahy <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS ICS[B /�A70/0 <br /> WORK PLAN DATED C Tb 2 1214, W12 p <br /> APPLICATION ACCEPTED BY 04f,"—k DATE REA /G / <br /> GROUT 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 SERVICE I RO# INVOICE <br /> p -r REQUEST PR`/# <br /> $125 x 4 eOG.nJ . C,-/U-74( SR# oq(p <br /> Zro3 3�S RO# <br /> 3500 <br /> PR# <br /> (2900 <br /> C-57 // WCy WAIVER I'd V4- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT // ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />