Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
CRIGIINA ', <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> : .i 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> SITE MITIGATION <br /> Telephone:(209)468-3147 Fax:(209)468-3433 Web: w.slaov.org/ehd UNIT N <br /> www.slaov.org/ohd <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 /> Applicatlon 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 /> French <br /> Site Location 500 W. Hospital Rd.CrossStreet S. Manthey Rd. City/State camp, CA Zip 95231 ApN 193-050-10 <br /> Property <br /> Owner San Joaquin County ,address City/State Zip Phone <br /> C-57Contractor:•Y — & A,a iat,a, 1— Address 215 W. Dakota Ave. <br /> Kr .. C rJSlote clo io, c (k 499908 Phone(559) 348-2200 <br /> Consultant/Sub Cntr",,..,,ro Address 215 W. Dakota Ave. City/Stat9 Clovis, CA Lic 499908 Phone (559) 348-2200 <br /> Blllable Party Address City/State ZIP Phone <br /> GISCoordinates:X 37. 886439 Y-121.282719 <br /> CONSTRUCTION RK TO BE PERFORMED: <br /> Lj NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER) <br /> ❑SOIL BORING IDS <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&N OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4.5" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapod Water ❑HAMMERIDRNEN CASING THICKNESS TYPE OF CASING: Q STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 2 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> 3 SOIL BORING ❑PUSH POINT(GP1 CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION Ma ArSmra&0awal[I HAND AUGER GROUT SPECIFICATIONS 94 TVVe I-II Cement/ 6 Gallons Water <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTH 2 0" ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING❑Na F-1 Yes:Casing Die: Ca"Depth: Boring Dla: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(.HECK ALL THAT AP y) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO Fr BFtow SURFACE <br /> COMMENTS <br /> NTS M TYPE TO BE USED:❑AUGERS HOSE El PI ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> CO <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this applic n and that the work will be done In accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a Califor laws. <br /> Signed Tltle/Company Senior Manager, Krazan & Associates Inc <br /> Print Name Michael Bowery D81e_4/28/14 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS_ '5bD IV- DI�l 6P(/+r &&4 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE IS1111hif <br /> ARRA <br /> GROUT INSPECTION BY FINAL INSPECTION BYCu DATE 'l-/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK N RECV13 BY DATE SERVICE RO# INVOICE <br /> i 0 <br /> REQUEST PR N <br /> 29'05 $125. l 7/�ll SR# s <br /> Z D 3 �S SE}f DOD 1/O l� RO <br /> 5500 <br /> PR# <br /> 2800 _ <br /> G57WC F WAIVER,,e C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2"1 SM9112 Q — SS-T - WELLPERMITAPP <br />