Laserfiche WebLink
Y I <br /> f {{ P4`-''•". 'SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SOP <br /> f �Ar� ITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 20 UNIT IV <br /> Telephone: (209)468-3454 Fax: (209) 468-3433 Web: ov.or leh <br /> II MENTAL <br /> WELL & BORING PERMIT APPLICAT rrIS <br /> HEALry <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REN1E[SON <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f 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 Develooment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. _.-. . . <br /> Site Location �l;t� -1tY, �I�IIY1 �:� Cross Street � it <br /> 'Woo D DIS City J�[�D_� Zip Y� APN �1 <br /> Property <br /> Owner (1VM Address City ��,,lZip Phone /� <br /> Address 3I03'� MEC C(ee'v� City RfW(�410 US�4ic Phone'7I(t•(o3P�• 1 <br /> fif C-57 Contractor <br /> I ConsultandSub Cntr Address q 5 fii .bG 40 D11 STC-126 city DLS�NI Lic Phone I I •`I1 5� 6�T-1 <br /> Billable Party M l7{S Address I t City i' " i Zip <br /> Sb3d Phone `r <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER) i} <br /> ❑SOIL 80RING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br />{ TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> —❑MONITORING [3 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING D1A: <br /> �❑EXTRACTION:Vapor!Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑FVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL »' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE EJ PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes El No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> (. —❑INJECTION i.e Air Sparge.Ozone ❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ! ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> i[ <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Ir <br /> { NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS;OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY I"AY .See; <br /> r OVER-BORE DIAMETER OF F7p Z INCHES TO DEPTH OF r'OC FTwak <br /> 'J,��-jj #OF WELL(S)TO BE DESTROYED ,iv <br /> PRESSURE GROUT TO DEPTH OF _FT BELOW SURFACE P— <br /> YVE`LL IDs: - MW' h�W'S 1tit1W <br /> GROUT SPECIFICATIONS c v-sm eve EXPLOSIVES FROM To FT BELOW SURFACE <br /> I. TREMIE TYPE TO BE SED E ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS _ _ - •5!7 5` - <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> it <br /> { 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 <br /> Regulations,and all applicable California laws. <br /> ii <br /> Signed Title/Company tQXltl D <br /> Print Name <br /> JuUV- D M00tJ ikV Date I lie 12, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS Z <br /> WORK PLAN DATED I 1. 1'Z, <br /> r APPLICATION ACCEPTED BY ( .a -�r"tt.�. !1 DATE ISSUED 2. AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY.' <br /> J DATE <br /> t DATE �S/: <br /> DESTRUCTION INSPECTI Y <br /> COMMENTS/CONDITION <br /> �- ACCOUNTING ONLY: AID# FAC# i <br /> SERVICE R0# INVOICE <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV-D BY �, DATE REQUEST PR# <br /> Saz $12' x S $ 5. <br /> SR# �>q L�� l <br /> So"� 3�-g�OID l ( o0) 03/ <br /> �� PR# <br /> 100 <br /> c C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT 6-f ENCROACHMENT DOC <br /> WELL PERMIT APP I <br /> EHD 29-01 07!28110 j <br />