Laserfiche WebLink
SAN JOAQUIN COUNTY FM ;9f L <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> SITE MITIGATION <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> T6i6phbhe.- (209) 468-3147 Fax: (209) 468-3433 Web: v,-v,w -gov.o _ /eh <br /> , .sj rg UNIT IV <br /> F mWELL & BORING PERMIT APPLICATION <br /> off El <br /> F (LskND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> i <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby Made toj§an.,,�ppqyijrL9ounty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Devel6p'me"n'i'Titfe,Chaoter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> I '-'q- 1 3 -C'r) <br /> Site Location,2qr, N, 4-Akc ! 4fz!tCross Street Kc"'\C-C City/StateS4.' �)-OA <br /> Zip_ <br /> Property Z7 3. 6c"-+-y <br /> + City/State 'i 5ao 1 PhoneC'i- 4(s L-,-939 <br /> owner[Ar.-:�-i(n -)f CPI Zip <br /> cy-N Address <br /> C-57 Contractorv,%,; 13 r-'kL'k Address 38CL-bu c-K Cre-tj�L i- City/State �-kA Lic 7:ZC)9C 4 Phone,�,Lq6:, <br /> Consultant/Sub Cntr 14 Lj f-V,lit EPA Lici)&7513 <br /> Address 10,; PU.rj City/State Phone 7-i7 -2q-(i' <br /> Billable Party(4orvtFz-Enu,rc.,tivvc-e,"WAddress 4L IT,? C ity/State el, c14 Zip '3 5 q 7,X Phone-7()7-F.-;1L/-/(d120 <br /> GIS Coordinates:X 3 7-CrTTqS- y -17 1. Lq&�i C <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> F9 NEW WELL/BORING(CP �6—PRO�BE HYDROPUNCH,HAND-AUGER,OTHER) <br /> [5 SOIL BORING IDs R a' 3L-3 ' <br /> ❑WELL IDs <br /> El OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE CC El MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION:Vapor/Water W>W*ff*1121 zN7 CASING THICKNESS _TYPE OF CASING: 0 STEEL 0 PVC El OTHER <br /> _Ej SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL —TREMIE TYPE TO BE USED. 0 AUGERS El HOSE El PIPE <br /> _�, (9 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> —EI INJECTION(i.e.Air Sparcie,Ozone)[]HAND AUGER GROUT SPECIFICATIONS <br /> —E]OTHER: 0 OTHER: APPROX.BORING DEPTH 'X0 ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING El No 0 Yes:Casing Dia:_Casing Depth:_ Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED Ej OVER-BORE DIAMETER OF_INCHES TO DEPTH OF FT <br /> WELL IDs: El PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Ej EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:[I AUGERS El HOSE [I PIPE [I MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have epa,ed this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> California <br /> ali <br /> Regulations nd all applic for.iajaw <br /> — 1 <br /> Title/Company el, <br /> Signe En V. <br /> Print Nameur V!T Date I a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS YoivrEP, I-Dt) <br /> WORK PLAN DATED o-oamummmv wmpztn <br /> APPLICATION ACCEPTED BY DATE IS4_4EP-1-r M MEA <br /> GROUT INSPECTION BY FINAL INSPECTION BY ­5FATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> V <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST I PR# <br /> $130. 2U\ I 32Z2-1-lq SR# 7ft'076 <br /> 3io <br /> -4R0—# <br /> (3500) <br /> t 3!�:)< f I —r(29OO <br /> C-57 WC V WAIVER AJ YJ- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT )t--ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />