Laserfiche WebLink
oP•`•'•'•'�• • SAN JOAQUIN COUNTY • � L -TP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: a <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENTAM <br /> \rq soft - Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:wwwsiaov.orcy+Eg111T}SfRVIC— <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 and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9--11115.3,and the Standards of the San Joaquin County'Environmental Health Department. <br /> Site Location //?Oat o A/AWafl l rC oss Street W07"h 900-OC City I-Lt�Zip 5330 APN (9,.5�-0,30-2-z <br /> OwProner � I��l�l�-L� Address �0/j��'�.sk'/319vCity eO Zip 98�Phone �6 .S0/ '{5/9 <br /> C-57 Contractor GYB�on/l/^L{ Address .1S'0 kkwGfwL city /YlGu'�/r1LZ Lic Zf /6.fPhone 9253/354'eO <br /> ConsultanVSub Cntr "R-S — Address 2VO6a /Oxlk-S - City Lic Phone 9/151(01 /3 <br /> Billable Party (AS Address owic fs�city Zip Phone <br /> GIS Coordinates:X 31. 8s I <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC 0 OTHER <br /> _0 SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS 0 HOSE 0 PIPE <br /> _D SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) �V <br /> _D INJECTION r e Nr Soeme.ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _D OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth:_ Boning Dia:_ r ^ <br /> COMMENTS: V <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL()�BE DESTROYED -Z OVER-BORE DIAMETER OF 10 INCHES TO DEPTH OF // FT <br /> WELL IDs: G i+�PRESSURE GROUT TO DEPTH OF //7 FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:E]AUG S HOSE PIPE MUSHROOM CAP AT L3 FT) AT- FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify thDffmo&�6 <br /> ed this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and �oloIrstURSSigned /�, ' / Title/Company <br /> Pdnt Name / LjUhJekCA _Dale�O .7-1/ <br /> � DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS I(8C NHQ/-IN Q •�' <br /> WORK PLAN DATED .IU 0/ Z. <br /> APPLICATION ACCEPTED BY DATEA M <br /> GROUT INSPECTION BY FINAL INSPECTION TE 8 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSIC ON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> SERVICE RO# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# INVOICE <br /> An $125 x /ZS ?-23-12- SR# GO([S/(07 <br /> y9rJ 3� R 00 <br /> PR# <br /> 2900 <br /> C-57 WC !i WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOCS <br />