Laserfiche WebLink
q�IrF ILE <br /> COPY <br /> SAN.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> e=:IIS < <br /> 1868 Hazelton Avenue,Stockton,CA 95205-6232 SITE MITIGATION <br /> Tele ( ) ( ) UNIT IV <br /> phone: 209 468-3147 Fax: 209 468-3433 Web:www.si4ov.orglehd <br /> (IFO(i <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 penult to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Locationta?aS l•thlk.k1C7N./.i C.Cross Street 11 &QIs City/StatelGp APN�y b^ly"�Is3 <br /> Property p, _ r+ <br /> Owner f?1eG 'Lvnoddress 7PIb /c!law City/Stale J p�Phone �5A04,�'� ©© � <br /> C-57Contrador t �� Address ?A At'%)4L S City/Stale _ - Lic b0 Phone 'i7g A'1'Ic'D. `^(�s�3?,8 <br /> ConsultantlSub Cntr Address City/State Lic Phone <br /> Billable Party Address City/Slate Zip Phone <br /> GIS Coordinates:X 3 7 7� Y / y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:- <br /> _[] <br /> IA_❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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 ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I,AV Soame 0-10❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑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 W EL )TO BE DKT' D 1 OVER-BORE DIAMETER of INCHES TO DEPTH OF & FT <br /> WE-LL IDs:�l—(_ S v Y'3 ❑PRESSURE GROUT To DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS�Rig ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:XAUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 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 prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and.211 applicable Califom'a laws. <br /> i+ s I 1 } <br /> Signed . I Title/Company � t/IZ Ylu OJ A I fl, l x. <br /> Print Name �� + Date—l J�1]L11 Z 1 1-1 A- <br /> nDEPARTMENT USE ONLY �t !C�� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /� 2W a7?V k R DifwE5, y <br /> WORK PLAN DATED 1.'z-1 Apo <br /> APPLICATION ACCEPTED BY J._q 61t x"a-I DATE IS � <br /> GROUT INSPECTION BY FINAL INSPECTION BY 11, DATE <br /> DESTRUCTION INSPECTION BY u" DATE <br /> COM M ENTSICO N DITI O N S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> REQUEST PR# <br /> -110 $125 x SR# <br /> RO# <br /> Xa &3 (3500) <br /> PR# <br /> 2900 <br /> C-57 ✓ WC v WAIVER 4./& C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC_ZC/& <br /> EHD 29-01 5109/12 WELL PERMIT APP <br />