Laserfiche WebLink
3 <br /> SAN JOAQUIN COUNTY <br /> c-�II—�F21 ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> • „'• 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.org/eh UNIT IV <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 install the work described. This application is made in compliance with San <br /> Joaquin County DCevtellopment Title,Chapter 9-1115.3,and the St dards of the San Joaquin County Environmental Health Department. / <br /> Site Location 15 L*�--+� W'W\ JI. Cross Street Ld- L City S{ j(W Zip 95206 APN 165-Did <br /> PropertyM ������� II ` ' ^ q <br /> Owner !"(� LAX�SIn( �IIVHi� Address C V 5� �Lt) l5 !Nf, City ,� Z✓t Zip tI� �3 Phone Y/G'',� <br /> C-57 Contractor 1�11 Address �-, c City -u S ,C pL-7ii. l g35 Phone 5.)—t/�/,OJ <br /> Consultant/Sub Cntr 14 'J ddress `A01(rin lk $ City CAvW4rn�/M��7y6L4e Phone �0-0i -2%,Z <br /> Billable Party V Address3.33D r,4VYI' ��, t? Cit�+l� r�►t/ N 15G�Z Phone J7 &-2rJ6 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN 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 e Air Sparge Ozone)❑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: MV-Ibj 10W-1-1 DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> G #OF WELL(S)/TO BE DES DYED (n !� MA L (j ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> (� WELL IDs:MW-I A(>,- ,U�W,VW-5 IT�('t'-� Irrw�l) �•Iw-l�)my-1 I,MW-1 V, ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIF ATIO S ivAa"01 01 ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> t`s TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS All 4/�I15 <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 /> Regulationsand 11 plicable California laws. Title/Company <br /> � t � 1 C <br /> Signed , y <br /> 4 F <br /> II� 2! zDlr <br /> Print Name 5 Tin � Date _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS -577�CO <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED 3 y AREA «s� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Z90-z- $122x /I 13`{2 °` Z50 32 CAII� 2 Z3 /r SR# 0062071 <br /> 290 -3 3G, 1( RO# <br /> C 3500 <br /> PR# <br /> (2900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />