Laserfiche WebLink
,..�.�. . SAN .JOAQUIN COUNTY <br /> ENVINMENTAL HEALTH DEPART ' LOP y <br /> r " SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202.3029 UNIT IV <br /> Telephone: (209)468-3454 Fax: (.209)468-3433 Web: M.SiQOV.or_q/ehd <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 instalt the work described. This application is made in compliance with San <br /> Joaquin County Development <br /> Title,Chapter 9-1'115 3,and the Standards of the San Joaquin County Environmental Health Department. t <br /> Site Location ao5 t 1 wQ Cross Street Glt � -y ff <br /> - - y zip APN I cas tD� €0 <br /> Property., -- City ? — -- <br /> , 6 �.1 ' �C 1 ' zi t -7'` <br /> Owner Address ,3CS� _ p s-� Phone <br /> C 57 Contractor __1j 1�!!.1 dress a i Ito - k-13�' City <br /> tbC' t r?'t Li' f 709 Phone._� -L°-��t�w j <br /> Consultant/Su Cntr '( Address City .. Lic Phone <br /> Billable Party (�C � 1� gadress '� t lex- I .. . Gity."'`��C�C,.I zip al PhoneG7 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> El NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,BAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs ". <br /> ❑OTHER los I <br /> f <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ` <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA; f <br /> _©EXTRACTION:Vapor/Water ❑;HAMMERIORIVEN CASING THICkNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSHROINT(GP!CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(-,.e Air sEm,.P..Ozaui❑HAND AUGER GROUT SPECIFICATIONS <br /> I _O OTHER: []OTHER: APPROX.BORING DEPTH ❑.BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Cas€ng Dia` Casing Depth:__ Boring Dia: Ol <br /> COMMENTS, Q <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: E_s RUCTION METHOD: CHE KALL.THATAPPLY <br />` Z #OF WELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF `f " INCHES TO DEPTH OF. �.� FT <br /> . WELL IDs: F E>-! . 'FC uSf R Lt r , ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE I <br /> TREMIE TYPE TO BE USED:W AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(a�31 T) FT SURFACE <br /> F COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have rep red this application�d that.the ork will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all ap Tirale lifornia laws. <br /> Signed \0 Yt 1 <br /> TitlelCo,nparry � � ���. - L nc <br /> Print Name `( t a;-N <br /> Date. <br /> DEPAR114ENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED (}C Tj <br /> APPLICATION ACCEPTED BY DATE ISSUE04_011711D AREA <br /> GROUT INSPECTION BY - FINAL INSPECTION�Y. DATE <br /> DESTRUCTION INSPECTION By DATE_'_ <br /> COMM£NTSICONDITIONS: i --- <br /> ACCOUNTING ONLY: AID## FAC# r: <br /> 1 <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REQUEST PR# INVOICE <br /> O 122 x �t0, LC �S !D I R 1 o SR# �S <br /> RO <br /> 35000 <br /> 2900 009/6 S� <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> £HD 29-01 07/28110 WELL PERMIT APP <br />