FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

Aar'" SAN JOAQUIN COUNTY LOP ENVIRONMENTAL HEALTH DEPARTMENT - SITE MITIGATION .� UNIT IV C 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3454 Fax: (209) 468-3433 Web:www.s*ciov.org/ehd LlFOR WELL & BORING PERMIT APPLICATION j 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. Site Location 7-PS00 HollVr';v,*— Crass Street Ar b a.r A✓en-!_ City '['ra«-1 Zip_ 9S 3o 9 APN 7-17-1 boil k Property — Owner S Q✓e Gkels S u5c,i Address P•o• €3o-K 4,D City Trac zip `I 5 3 1 S' Phone zsg S i-7107 C-57Contractor v:tw' Dr:t+:r1 Address ?ked Arc L- cies4 Br:NC _ City S4°cAL4&,., Llc 7z° o Phone (74011401' 170o 4�� ..�- era GonsultantlSub Cntr hrVar-�n,a� t'..<. Address' 17.!4 4 ce-I•- City Escu lw. _,Lic PG- FIctIY Phone (z��r)Ff zf-Skirts v� Billable Party Address 7t"^*�ze« t 5freef City Esawlc-- Zip 453Z� PhoneCzagl�?sr-yg�� �.-�. �a:� GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE 8#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: t _❑EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN 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(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Qi.e.Air Soame.Ozone)❑HAND AUGER GROUT SPECIFICATIONS f _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: r COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY), A #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF _INCHES TO DEPTH OF_Z0 FT W LL IDS: W -13 R PRESSURE GROUT TO DEPTH OF `FT BELOW SURFACE= GROUT SPECIFICATIONSy tK4- EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:IW AUGERS []HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS,NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 4 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,and all applicable California laws. Signed v-C- \j -00 Title/Company Urdu^d ZE�� Arun e� "fa.'F>C �-F'fr .J� Print Name ° V�t B 7� Date--21 r I _ DEPARTMENT USE ONLY Loi sit od-c�: c� SITE MAP IN UNIT IV FI -SITE ADDRESS �6 Q0 �- � WORK PLAN DATED (.til--.--- L I qq qq-�7 APPLICATION ACC T D BY DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE 1 I COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV' R P D BY DATE SERVICE # INVOICE REQUEST PR# ! 356 $122x ZZ O ! 7 �7f� SR#�Z ! �� Roo 0 ' PR# 2 100 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 07126110 T - i