FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

e eQR41N. .. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT •• )."'.�' 1868 Hazelton Avenue, Stockton, CA 95205-6232 REQ fiD `')•a:RN Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.s(gov,Gra/eh WELL & BORING PERMIT APPLICATION JAN 2 3 2015 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRFFONM�ENTALHEALTH Application is hereby made to San Joaquin County fora permit to construct and/or Install the work described. This application is made�n'ticRmpltancewith San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 4b4S Lcct IKRi'^ Cross Street _OVp .,rr Property A., /+V2 City/State S� �.Zip APN !57244.1(4M Owner 111-Dr-111 Address P.o. BOX 3Z4 I 6+o City/State f -foh Zip 20 1 Phone C-57 Contractor TFG-N„SR.✓.Csl Address 11350 Meti c� \l ao, City/State Ind G A v,1ic L46 50 Phone'jl6-h+s •Ffozo Consultan iSub Cntr Ccvl"n Address Ila iI V Is,'Aw % 201 City/State Mje<4j Lic Phone Z7°/-515-2221 Billable Party_ GcvjMo Address City/State Zip Phone GIS Coordinates:X y CONSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEOPROBE,HYDRO [I SOIL BORING IDs PUNCH,HAND-AUGER,OTHER] ❑WELL IDs 0OTHER IDs Sosl VMu✓ Lar TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM CIA.OF BOREHOLE-(&10 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS ' TYPE OF CASING: STEEL ❑PVC OTHER Ta�Clos. $®SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GRet1P SEALS/ � _0 SOIL BORING TREMIE TYPE TO BE USED: [I [II]AUGERS HOSE PIPE 4 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION O.e.Air SnameO ))]HAND AUGER GROUT SPECIFICATIONS _❑OTHER ❑OTHER: APPROX.BORING DEPTH S/ I ❑BOLTED TRAFFIC BOX OR EI STOVE PIPE / ,0 - .4/ )i<�r' 'j, CONDUCTOR CASING�((No❑Yes:Casing Dia: COMMENTS: rcw' opy y, Casing Depth: Boring Dia:_ NOTE. OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: —#OF WELL(S)TO BE DESTROYED DESTRUCTION METHOD•(CHECK ALL THAT APPLY) WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT GROUTS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE E]PIPE ❑EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 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 ail p icable California laws. / Signed , �- Title/Company-5A9 Print Name _� I�_ ({ ��-1� � DEPARTMENTUSE ONLY Date J ti v A/ 0.S SITE MAP IN UNIT IV FILE-SITE ADDRESS_ L075- F// C r IOY1 Q ' C'�- WORK PLAN DATED 4 APPLICATION ACCEPTED BY DATE ISSUED /9/ jyr AREA�9 GROUT INSPECTION BY FINAL INSPECTION BY 7-j DESTRUCTION INSPECTION BY DATE DATE COMMENTS/CONDITIONS: b,es SVII-I ACCOUNTING ONLY: AID# FAC# SYPI PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# q REQUEST PR# INVOICE $130x Q ()• �V 6 / 02- c.OUn��-,- / Y$ sR# 60`72 2117 RO# (3500 0000 679 PR# C,572900) EHD 29-01 7124/14 WO WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP i