Laserfiche WebLink
2 <br /> SAN JOAQUIN COUNTY ...� <br /> )O��'-•COG <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �•�•.•— --+��• 600 East Main Street, Stockton, CA 95202-3029 <br /> SITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.orcgleh 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 Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 65— - /) !� <br /> Site Location I V4 5, LACjo S-I. Cross Street w' AK AJ14ityy�Lk Zip APN i �✓" V <br /> Property CC��� <br /> Owner A10 CiA- Address p.0 r :JdX (C 566 City Z485&6&6 Phone I bit-'V iL 55/6 <br /> C-57 Contractor kk1 Address 6MM"WiX Oa" City ( nu S i Lica 3� 52 Phone 530-0V-!kc/ <br /> Consultant/Sub Cntr BA t �JxVress 3330 Carruro 1P-J0-.�t 55P City/cfiotl+n q�,�k Phone�� <br /> Billable Party � _ Address3332�4rAP g Ds, c7 CityG01I4k L)4. ..pg(5&YZ Phone 3 7G-21* <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 a 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 /> P/ NITS: <br /> k' �} NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED:Irw-11)SGW3jsGW-U)Sbvi-S DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 1 ,l) riU_#OF WELL(S)TO BE DESTROYED w_ [:]OVER-BORE DIAMETER of INCHES TO DEPTH OF FT <br /> WELL IDs:ASIS/tS-3.A�ZtUt�-i,VwZ,vw3w <br /> �� -►3,r�w-Z�j�w-5}r�1w-r2� �❑ PRESSUREGROUTTODEPTHOF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS Affix M2nt ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BSED: ❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS Qb�1dJi 41 VW-1,VW-3,S6wU -2,, jS W- KSSb/( fur:t c7I I (�414 S <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,andall a plicable California laws. <br /> Signed Title/Company Pte) <br /> Print Name S �� (h Date Z I- ZDI I <br /> DEPARTMENT USE ONLY A 15 ovwdrZ11 - MW I I Mw 121 AW t3, Mw'2 <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS SL.�«/ kith MwSu +`'tW 7 <br /> WORK PLAN DATED //// <br /> APPLICATION ACCEPTED BY _ 9�G111 / DATE ISSUED AREA 1"1 S3 <br /> GROUT INSPECTION BY /�Ut//C/fin �.tl,yetAt FINAL INSPECTION BY /�/1��I` svrv� 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 I RO# INVOICE <br /> REQUEST PR# <br /> 296 2 S 122 X 15 153 2 032 CN7"IZ SR# 0 2076 <br /> Z9v3 364 36� 2So3Z Ro# <br /> 3500 <br /> PR# 527( ! <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 />