FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

CEIVED �^ SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION JUN 15 2011 600 East Main Street, Stockton, CA 95202-3029 UNIT IV c ; P Telephone: (209) 468-3454 Fax. (209) 468-3433 Web: www.sigov.org/ehd IFOR ENVIRONMENTAL HEWW LLL & BORING PERMIT APPLICATION PFA WELS RLCES 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. j Site LocationoZ085 (�. IDSO(O Y Cross Street L AVICEL FT. City 45;m7oelK7aN zip_551oS APN hll - HZ ' 03 Property Owner CJ!NErT FoP?IAAIo Address TJ13 N . KNO1r I2 . City 6 / NDE Zip 99�03 Phone ?o?4 F093 C-57 Contractor C ASCAaC Address 7A oyi 6CiA CILCLG City 'L=c -C=A Lic939U O Phone WKi 638 IV? ConsultanVSub Cntr A7c. Ac'ae/ Are§Addfess /[I? CoA/C- PALP4 AVC City WoaESTa Lic 9X7 76o Phone T793.7 1 Billable Party Address City Zip Phone GIS Coordinates: X Y COSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) E] SOIL BORING IDS 20WELL IDs OS OS OS ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING. 2<01-LOW STEM DIA. OF BOREHOLE I Z' ❑ MULTIPLE CASINGS [] MULTITEVELL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 5 CH 80 TYPE OF CASING: ❑ STEEL LTJ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL SS I TREMIE TYPE TO BE USED: I] AUGERS ❑ HOSE ❑ PIPE _,EI SOIL BORING EI PUSH POINT (GP/ CPT ) GROUT SEAL PUMPED: p-Yes El No (MAXIMUM FREE FALL DEPTH IS 30 FT) _LTJ 'NJECTION 0o Alr Brame. Ozone) E] HAND AUGER GROUT SPECIFICATIONS N eA 7 C em E N —0 OTHER: ❑ OTHER: APPROX. BORING DEPTH 49,02 90 2 ItOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING LTJ No El Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: SEC A-?CS IGE-A1Eh1AL. &Ccriot P4A . J Dh%En RP414_ 29 zoll NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECKALLTHAT APPLY) _# OF WELL(S) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL-IDs: PRESSURE GROUT-TO-DEFT-BELeW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO Fi 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 prepar d t ' application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and T Regulations, and p able Ii nia laws. Signed Title/Company SE'Ay/oX C- C Loc lS % ATC A9SOCr4lc�S PrintName � � /�� NC- Date 7 / DEPARTMENT USE ONLYn Lt Y SITE MAP IN UNIT IV FILE - SITE ADDRESS ZC5 $ S' �-e tnaor..v4 I_ S �3 6 rL WORK PLAN DATED 4 29 It APPLICATION ACCEPTED BY LzbnAeA DATEISSUED AREA GROUT INSPECTION BY Ul w� t;(201 ill FINAL INSPECTION BY IAr�AA�C- e-ee DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE q REQUEST PR # 3 0 $ 122x 3t66 • oo Oq � 3l� L' If 11 SR# Z7 �TZ 35 e) J66 00 3500 PR # 2900 C-57_ WC WAIVER C-57 LEITER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTDOC EHD 29.01 07/20/10 WELL PERMITAPP