FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

I SAN JOAQUIN COUNTY � RE ENVIRONMENTAL HEALTH DEPARTMENT Lj Q: N' l '• 600 East Main Street, Stockton, CA 95202-3029 FEB YTfflTj' ION Telephone:(209) 468-3454 Fax: (209)468-3433 Web:www.sogov.org/eh F o a NUIRONMENTAL H WELL & BORING PERMIT APPLICATIONS PER ITL�� EALTW FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME 4Tr@�VICE$ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development lTitle,Chelpt r 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. 5AC.1uU" t i.l tfJg7l�� r , / I } �.f Site Location I S{ ,V S. t-i+1Lo1.1 S1. Cross Street Lk� W /tOL city I'DC� M Zip y52 1 APN kl 0;'U Property -1r [ I - Owner C C � Address ��5 N 61 N D City SI�(,i�� Zip Phone x-737-,/331,6 C-57 Contractor � Address i ck City Q( Qp41�) Liic P935`/ Phone_'530 y6 -140 f Consultant/Sub Cntr J I�dt�ress 3330 4ntrror�P�,K4D-.i,�1 ,r?,D City/CAV"h%MP4'Ij7ypLae Phone !�- G-�Z Billable Party Address333o Mf 4j9r,jt- Sd Cityl.t m&k P4 ..p gs6n- Phone 3�W&-20G GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL 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 _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i a Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING ElNo[:IYes:Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) �• —S_#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ft-5, . GAd–). 6W--1 ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE n )l GROUT SPECIFICATIONS t\? Ca?4-0 ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE El PIPE ❑MUSHROOM CAP AT(>3 FT) T BELOW SURFACE COMMENTS_r_� )YI W-,Ltt 't( 5�>/ 1� . Gtd ?. i✓/ aL5-�1 M 1Al n%j 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and alta plicable California laws. ,,//�� /' Signed C ff Title/Company P1)C[[�f•'�/; /[9'GO16S�S Print Name Date ZDI I DEPARTMENT USE ONLY Mw3) SITE MAP IN UNIT IV FILE-SITE ADDRESS �7Zli S 1iiZca�/9 �� STocG�r WORKPLAN DATED ��// APPLICATION ACCEPTED BY /vC DATE ISSUED AREA lS� GROUT INSPECTION BY _01.x.. FINAL INSPECTION BY DATE 31' 1,7 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# Z9 OZ $122 X �� 25032 CSV;rZ ?' z3�Il SR# 00(oZ073 RO# 3500 PR# 5Z76 it (2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP