Laserfiche WebLink
F ` �y SAN .JOAQUIN COUNTY • FILE COPY <br /> ora!!y Q <br /> T <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> one: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov.org/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> �NQ�PNI�MHDR 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 520 N. El Dorado gross Street Fremont St City Stockton Zip 95202 APN 139-060-32 <br /> PropertySugene & Darlene Warne 372 S. Locan Ave Fresno 93727 N/A <br /> Owner address City Zip Phone <br /> Advanced Geoenvircnmental Inc 837 Shaw RoadStockton 680227 209-467-1006 <br /> C-57 Contractor <br /> �r1 Address City Lic Phone <br /> Consultant/Sub-Crvrtanced GeoEnviroAaeental, Inc. 837 Shaw Rd CiltStockton Lic 680227 Phone 209-467-1006 <br /> Billable PartyBabu Sagireddy Address 801 East March Lane City Stockton Zip 95210 Phone 415-990-0125 <br /> GIS Coordinates:X Y 'I?( , ),?( <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> p� <br /> ¢NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) Cr <br /> )9SOILBORINGIDs B9,B10,B11 (30'bsq, & V3,V4,V5 & V6 (5' bsq) N <br /> ❑WELL IDs <br /> ❑OTHER IDs Z <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA'. <br /> _0 EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER <br /> _O SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> USOIL BORING )UPUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) A <br /> _0 INJECTION(i a Air Soame.Ozone)0 HAND AUGER GROUT SPECIFICATIONS 94 LB PORTLAND + 6 GALLONS WATER <br /> 0 <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH 3 0' and 5 ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE D <br /> CONDUCTOR CASING O No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ 6) <br /> COMMENTS: see attached site plan. <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> _W #OF WELL(S)TO BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DEPTH OF FT <br /> ELL 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 /> 1 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 app' bl ornia Laws. <br /> Signed Title/Company President <br /> Print Name <br /> Robert ty Date 03/05/12 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS 5 Z42 ti CL I)61Z✓-j•()O 15/ <br /> WORK PLAN DATED .J N Z0f Z <br /> APPLICATION ACCEPTED BY DATE 1 EA /(199 <br /> GROUT INSPECTION BY FINAL INSPECTION BY TE S <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICO N DITIO NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICEST PRRO If <br /> QUE # INVOICE <br /> RE <br /> 290S $125xI R AjL L-1 U s. t2 SR# GNSZ <br /> RO# <br /> 3500) <br /> PR# <br /> (2900) <br /> C-57 WC r— WAIVER a C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br />