FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ORIGINAL E RONMENTAL HEALTH DEPARtM ENT K/ILOP SITE MITIGATION 1868 Hazelton Avenue, Stockton, CA 95205-6232 UNIT IV C'.q77,; Q' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:WWWsi- ov.orcilehd FOR WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION OAJ` 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. Site Location Avttit-4- Cross Street VICU f b ✓"t- City/State 5r9e.IC VAZip 9S2,0) APN 08Z--'1a0-V9 Property Owner tLi1*;?% Address 3ZSy In!. 65 o�ulw�er �J9.City/State Sht C,k('ovlZip q ZD g Phone X09 —41!y— ?12-'rC-57 Contractor ddress 42K$ 13 D/`� Ske- City/State �_4Lic 8q 3s9 Phone 9!(p^j�=i^43sS Consultant/Sub/C1ntr Sfra I els �.M V•Address333O COu>dtroll N• 1N`S Sd City/State 44-6 Lic PG'x577 Phone S'310 '�76o Gds Billable Party SfrahAt CAV. Addressj'V:50 pit•I]/'• City/Stateea,w2rM Zis� b$ Z- Phone S 30 GIS Coordinates:X Y STD PA-rIL CONSTRUCTION WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED: ❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(Le Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK4LL.THATAPPLY) _7#OF WELL(S)TO BE DESTROYED ,/ (XOVER-BORE DIAMETER OF INCHES TO DEPTH OF Z s FT A WELL IDs: .[./—I --V A4 W-3 IW'I ""D I W_ I 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ✓I ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: UGERS ❑ OSE PPE N ❑MUSHROOM CAP AT >3 FT� F BELpw SU�Z�CE COMMENTS k/— ' 2'1 W-- &VI g C?� t4A — ' 0 o- � /'� /o 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 Regulations, d al pplicabl laws. / - / Signed - G. Title/Company ir. Print Nam ke.i Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS _tom S /C7 WORK PLAN DATED14 ^ / C� o APPLICATION ACCEPTED BY .I. yU'y/Clivi, DATE ISS 2!& GROUT INSPECTION BY FINAL INSPECTION BY DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 35_O 2 $125x 7SSS- 7-z2-t' sR# 76 7 'S Ro# 3500 PR# (2900 C-57 WC WAIVER Alj�: C-57 LETTER OF AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC FHn 29-0 5/09/12 WFI I PFRMIT APP