SR0069847 - Laserfiche WebLink

Home Browse Search

.- REUBWOINAL Pq�iN SAN JOAQUIN COUNTY JUN 09 2014 ENVIRONMENTAL HEALTH DEPARTMENT LOP �. SITE MITIGATION '• 1868 Hazelton Avenue, Stockton, CA 95205-629YVIRONMENTALHEAL7MIT IV �A�/FORa`P Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www.sil 'W-MBEftwees WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. I 61-C �-'{ZDa 2- Site Location'l033 E-c.5t YW_ry A4_Cross Street yciSc0-hf16 AV<1- City/State. cs,Zip , APN I%- Property n� ,�G c� Owner t uxOfcty. �cwK.�„Irk ' Address +�-Ic� „�Ya,,, (.1J1 City/State Zip ��LLO Phone 26I-aA _3300 C-57 Contractor TECs - I�c�. C c.I Address 11350 Iv�Cr l? kL flucQ City/State Lic"-0fo5(o$ Phone R ha-853 Q61O Consultant/Sub Cntr&_v' j�,a.. t Address 3135_W -,—YPeU P� #D City/State u Lic Phone &l-_T'�l `Z�6� Billable Party o r +Address -'-hh rllwrfa.. Ong City/State,�Zip !IS Z IU Phone ZTj -S s-`co - GIS Coordinates: - Z. Y 1'2-1 - jj -0.1-i 7- 2L &(0 CONSTRUCTION WORK TO RIF E RFORMED: JR'NEW WELL/BORING(CP EOPROBE YDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z 1+. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _3LO SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _CK SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes No(MAPMUM FREE FALL DEPTH IS 30 FT) p _C1 INJECTION(i.e.AirSoaroe.Ozone)El HAND AUGER GROUT SPECIFICATIONS -!J��/v Of4� �Pax4 5, 7- 4Ly_ ❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:C�s,ing Dia: Casing Depth: Boring Dia: COMMENTS: � C�7�P_1 rx...�c� S Pc�F. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER of INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulation all icable California laws. C /, Signed Title/Company C_��-+7��( c*n C4 z"C' Print Name to e c7 Date b1s1 4 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS73 C, yr1')I%C M�N% A WORK PLAN DATED J c4 NC Zv f`1 APPLICATION ACCEPTED BY .I- ` c)✓J-X'ir"\ ED 6 IrZ I AREA4 GROUT INSPECTION BY tf DATE /2-3b-/Y DESTRUCTION INSPECTION BY D COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# IO $125x Z� , .(� SR# 8�(7 U� 3�5 RO# 3500 PR# 2900 C-57 ✓ WC `� WAIVER '4'4 C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOCS EHD 29-01 5/09/12 WELL PERMIT APP