COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

/41'". SAN JOAQUIN COUNTY >. E.t•-.. LOP ?. ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION • 600 East Main Street, Stockton, CA 95202-3029 • cq�/FOR�� Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s' ov.o WELL & BORING PERMIT APPLICATION 1 all FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMED NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicat Ith San Joaquin County Development Title,Ch pter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Dep (35_NG. ,'Z 73��f rti( �N-x —oN Zl 13S-Yb V Site Location 4 Sr.►N/L i �cc Cross Street City WCK—, Zip CJS 3 APN Proper, r, Owner/ "4ry 6j✓ 5oGY�10' Address �25 N �l- V�24�0�317 city S`b N -zip-F�y b�Phone a 7rF5 I C-57 Contractor T1= (SO(L�rr� i�Address City Lic 1Phone Consultant/Sub Cntr Cr'.,.rt 1N> DwF.`Address 10`C1lJ( r I(1 IZ` �°cK (-j City RA-C a 64)a is Q"7'D Phone 211, YyY D-*Z> Billable Party 6eo.-- A,'D Address /oSYJIli-(M1 /Lec.IL lZf> City6 )aJFZip�-��Phone et 16 '/Y4761�3 :W3g� GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: I&NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) aSOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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 (u nSOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE Z JU SOIL BORING ®PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) __ ❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER_ GROUT SPECIFICATIONS PeAT � ___❑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:(CHECK ALL THAT APPLY) #OF WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L?