Laserfiche WebLink
�,s•Ia� SAN JOAQUIN COUNTY <br /> COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> . 600 East Main Street,Stock on, CA 95202-3029 SITE MITIGATION <br /> Telephone:(209) 468-3454 Fax:(209) 4(i8-3433 Web:WWw,sigov.orglehd 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 Sen Joaquin County for a permit to construct and/or ins^all 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,oaquin County Environmental Health Department. <br /> Slte Location 520 N. El Dorado Tfoss Street Fremont St _ City Stockton Zip 95202 APN 139-060-32 <br /> Properlu ane & Darlene Warne 372 S. Locan Ave Fresno 93727 <br /> Owner g Nddress _ CRY Zip Phone <br /> We onement 45 Beatty rave au to A Oi aCie . I'9Lip an�399 Phone :-916-16J-9355 <br /> C-57 Contractor <br /> Address b <br /> CansultanVSuA xlance GeoEnviroMe�nstal, Inc. 637 S aw J' CltyStoc�tOn--Llc PnonE09-457-1006 <br /> EIIIable PartyBabu Sagireddy Address 801 EastEastMarch Lane City Stockton Zip 95210 Phone 435-990-125 <br /> GIS Coordinates:X 39 S 7 Y "1�)'.Z ' r <br /> CONSTRUCTION W, ORK TO BE PERFORMED: <br /> K NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH.HAND-AUGER,OTHER) <br /> U501LBORINGIDS SB-1 thru SH-6 O <br /> ❑WELL IDS -- <br /> F1 OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_._ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapod Water 0 HAMMERIDRIVEN CASING THICKNESS -. TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT S&I TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 13 PIPE <br /> __)MOIL BORING $XPUSH POINT(GPI CPT) GROUT SEAL PUMPEC 0 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION a e Ar So.,Orono)0 HAND AUGER GROUT SPECIFICATIONS 94 LB PORTLAND + 6 GALLONS WATER <br /> _0 OTHERI ❑OTHER: APPROX.BORING DEPTH 2 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING-.7 No 0 Yea:Casing Dia: Casing Depth'_ Being Out_ V <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK T°BE PERFORMED: PoiRUCnON METHOD- LLAT APPLYI <br /> _#OF WELL(s)TO BE DESTROYED LI OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT .7 <br /> WELL OF <br /> C]PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE C <br /> GROUT SPECIFICATIONS _ ]EXPLOSIVE FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE ]MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT 103SUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I hays prepared this application and that the work will be don,in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appllcab atornia,Laws,--- � �.-.,..pF�111 (R�1`�,.7 /' /\ <br /> Signed <br /> - -_ - <br /> >_ TILIelComR my Will, `lel me 11 <br /> PrintName t.. 'sNFl< (x Date 1l11Ut 2..l-'\\ <br /> [[-- <br /> DEPARTUS ONLY <br /> SITE MAP IN UNIT IV FILE SITE <br /> �AiD�DRRESSSS -1 20 lU• C4•VbQJ9D <br /> WORK PLAN DATED_L:_-x0­ _1_," ZQIL__-- ---- _ qp <br /> APPLICATION ACCEPTED BY I CIOi'yA-KWL DATE ISSUED �.—.._AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGftAID _. FAC# SERVICE RO# NVOICE <br /> PE CODES D CHECK# RECV'D BY DATE REQUEST PR# <br /> 2�dS b59- <br /> SR#3flo7 eA�A, R II z-(/ ;°#z to3 C-57 C57 LETTER OF AUTHORIZA110N TO SIGN PERMIT —.r— ROACHM ' D)C U_r�_ <br />