Laserfiche WebLink
ONGINAL <br /> ,,A'61A.I�S <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> SITE MITIGATION <br /> ' J. 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV <br /> • c�;,, ;:.�;;� Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:vvww.siclov.orglehd <br /> �l <br /> ;4 60 <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 andlor install the work described. This application is made in compliance with San <br /> Joaquin Count Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County vtro men/ I Health Department. <br /> q Y P ��""''��`` LP ����� <br /> Site Location��d tl) t�rH 41 Sf • Cross Street City/State _C►�Zipil APN I q ,1 CC)LI <br /> Property 9T.(h{[Y1 '7 �?i <br /> Owner /IJ QL�i Ly �L C-TYDV e)Y1 C. Address ��l) w (�r11,1Ift'k �. City/State (/� Zip J Z L Phone <br /> ��r�� �i i <br /> C-57 Contractor C-j CYI. cldress q5-� �Q City/State _Lic ql(0`7 Phone%25hl?16L�07) <br /> Consultant/Subtunir Address IUCJ La e Se�h�fl fIdCL City/State Sajt• u Lic9�� 2-'lt PhoneYU8f.-t.7 S <br /> Billable Party <br /> Address ° r� Z00 City/State ll " Zip � rr Phone <br /> GIS Coordinates:X 3 Y <br /> C NSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER) <br /> [],SOIL BORING IDs i <br /> LOWELL IDs ' <br /> El OTHER IDs da) <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE � _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CAW-G:,- <br /> ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE DF CASING: ❑STEEL XPVC n )rr*. <br /> ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑•UGLAS O N--sw O PIPE <br /> _❑SOIL BORING ❑/?USH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes El No(MAXIMUM FREE FALL DEPTH IS lC FT, <br /> _❑ on <br /> INJECTION(i a Air Sparge.Ozone)[I HAND AWPPj �_5�GROUT SPECIFICATIONS <br /> ❑OTHER: [I OTHER_ - APPROX.BORING DEPTH ❑BOLTED TRAFFIC:BOY ON "``4 PIPE <br /> � COf�D CTO CASING O No❑Yes:Ca iq Dia: Casing Deplh ____ bum,..COMMENTS: CL(� LUeQ(S h LJlt 1� X1(1 1 ht S <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PEPJAr% <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THATAMT1 <br /> _ #OF WF'�'^`-1 BE DESTROYED ElOVER-BOREDIAMETER OF INCHES TO DFPT4 ry <br /> W _FT <br /> ELL IDs: n PRESSURE GROUT To OFoTH OF_ _r'10 :re ACE <br /> GROUT SPECIFICATIONS [ EXPLOSIVES FROM, TO rT 6f, '- 4coRrACE <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) FT SU**ACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMEN•t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinancew oul*s and <br /> Regulations,and all app/ California laws. J <br /> Signed � 4/t Title/Company Z' -61 'r <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS CTU 0. C(�KQCH S TKE6,T" S`EY KTOO <br /> WORK PLAN DATED TV F / <br /> APPLICATION ACCEPTED BY J.116 V.1-K"I" DATE I A 16 <br /> GROUT INSPECTION BY FINAL INSPECTION BY u DATE "y l <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# <br /> ;L i v $125 x ( 1375 o 2-`10•-1 y SR# 6 9 U'Il 1 <br /> RO# <br /> �90 3 37� 3P5' (3500) <br /> PR# <br /> 2900 <br /> C-57 ✓ WC ✓ _WAIVER_ ��__ C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT &/ ENCROACHMENT DOC <br /> EHD 29-01 5/09112 WELL PERMIT APP <br />