Laserfiche WebLink
In SAN JOAQUIN COUNTY` <br /> LOP <br /> ems•, <br /> `{ ENVIRONMENTAL, HEALTH DEPARTMENT SITE MITIGATION <br /> •`: '• 600 East Main Street, Stockton,CA 95242-302.9 UNIT IV <br /> Tdlephone:(209)468-3454 Fax.,(209)468-3433 Web:.tivlvw slgorr.oralghd <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMED1ATtON <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> AppiiGallon Is hereby made to San Joaquin Counly for a permit to construct andlor install the work described. This appticallon is made in compllan:e with Salt <br /> Joaquin County DeveloprrtwtTItlgE Phapter 9.1115.3,and the Slartdarft of the San Joaquin County Environmental Health Department_ <br /> SlfeLocadon M*.r1 VPM $040- City tvtk4.'Mrr-Cf Zp 2� 3 APWzz1-6z-0"`2-%-- % <br /> Property <br /> Owner.r_t'Y"tt €7 tit >6 Address'NOOk Qi,t.GEt�i .8T-, Gltr T-vAMt4+ 'R�t Z�yS3 'I . Phone dr'f'"i ,-21(0 I <br /> C$7Contractor iStlt6}t Address tl;Rlt Wit, C"rlty Lest Lic'71en_ Phone <br /> Consultant)SubCntr 1�+iwc oto 'Address %AD =YJ City +JSil t .QPk .LIC Phona jw-r ALkat, 5 <br /> 8111ahld Part] Address City^ Zip Phona <br /> GIS Coordinates:X- o -y E ` • Y' tit° � "' <br /> CONSTRUCTION WORK TO BE PERFQRW <br /> 4 NEW WELWOORING.(OPT,GEOPROBE, PUNCH,HAND-ANGER,OTHER) <br /> ❑SOIL BORING IDs <br /> gI WELL IDs �Li S' ,.:. re.tsa-Z. r,Ls..1 Lai <br /> CI OTHER If3s <br /> TYKE 8#OF WELIJBORING INSTALLATION,TYPE CONSTRUCTION SPgf4IFl!g4X0NS <br /> ,_,q Pott NITORIING ©HOLLOW smv CIA.OF BOREHOLE �-rl O MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING CtR_ <br /> O EXTRACTION"Vaporl Wat9c 'EI l',+,k1MEX1313MRtiCASING`HICKNESS "` TYPE OF CASING: 0,STEEL 0 PVC 0 CTHE R <br /> _I i 4I1 1/APOR BR013E EI h1IJD fibT►lFiY DEPTH OF GROUT SEAL TREbIBIE TYPE 70 BE USED; CI AUGERS E3HOSE Q PIPE <br /> sLZ SOtI t3dRINC;< j6pUSH Pot jvT(,GwGPT) GROUT SEAL PUPlPEd [I Yes []No(MAXIMUM 1 REE fA.i DEPTH IS 30>•T} <br /> _C?INJECTION(I e,mr_spirum Oars ©FAND AUGER GROIJwECIFICAm6.NS <br /> O*ER: ❑OTHEM APPROX.BORING DEPTH $t Cl soLTEO TRAFnc Box OR CI 3Tove PIPE <br /> CONDUCTOR CASING UtNo CI Yea:.Qatfns Dia; C".ng Depttl Baft Din, <br /> COMME14TS: <br /> NOTE: OFFSITE WELL,S.&BORINGS REQUIRE ACCESS AGREEMENT$,OR ENCROACHMENT PERMITS <br /> DESTRUCTION woRk TO aE PERFORMED: OESTRUCTION MET14OD:iCk=Cls ALL J[ AT APE Yt <br /> li of WELL(S)To EE DESTROYED ❑OVER-BORE DIAMETER Of NCHESTO DEPTH CF FT <br /> WELL IDs: 0.PRESSURE GROUT To DEPTH OF � � FT BELOW SURrAC.E <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM - TO f'BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS C1 HOSE ❑PIPE ❑MUSHROOM CAP AT t3 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 applicollgn and that tlla_v 6rk WO be done In accotdanoo with San Joaquin County Ordinances,Rules and, <br /> Regulations,and all applicable California laws. <br /> Signed <br /> - `"'- itlelCompany, +REosc.I< t`rl+atCac� : -- e1�t.e9Ss �' 'Y <br /> neo <br /> PrIntName Date tzt-.7L't- e�s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY BATE 16SUED AREA <br /> GROUT INSPECTION 8Y FINAL 04FIECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDI TIONS. <br /> ACCOUNTING pN.LY` AID 9 FAC 4 <br /> PE CODES FEE INFO AMT REMITTED. CHICK# RIECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> S 122 X SR# <br /> RO# <br /> 3500 <br /> PR# <br /> 290© <br /> C 57 WO WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCR4ACH1�IENT DOC- <br /> ::H,029-01 0112W10 'AgLLPERMITAPP <br />