Laserfiche WebLink
i <br /> • • FILE Copy <br /> SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone:(209) 468-3147 Fax:(209) 468-3433 Web:www.si4ov.ora/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 /> Appilcation 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 Stand ds of the San Joaquin County Environmental HealtryOD^patfm nt.c�J�,,,,0.'- 11/5--020'08 <br /> Site Location (s S r nCross Street - Or City/State�or-�o�5 1p— APV 11/0 <br /> Property "4401 <br /> r <br /> owners W td6ex MeA��ss ..2Y 1'O S. Alii t"i 4k)l CitylState"44 Phone 6 6 dy00 <br /> C-57 Contractor ULtY- Ky'.) ffAr 1A�ddress �,._g _e Rk 6I.S 0 1�O'ityl�S ate A Lic 2P33Ab Phones (o ��10 <br /> Consultant/Sub Cntr q&,p •er nntM lAtl�iress WI i C � Wf`City sate�LicWg4 Phone Alk)6 1 -0 <br /> �rO b -0 010 <br /> Billable Party �c /1 Address 0 A PG(ty/State � Zip `' � Phone , <br /> GIS Coordinates:X <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(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 /> _pq-MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE _ 0 MULTIPLECASINGS D MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS D HOSE 0 PIPE <br /> _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION fIa.NrSoaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR D STOVE PIPE <br /> O Vt IAL ASCONDUCTOR CASING 0 No D Yes:Casing Dia:_Casing Depth:_ Baring Dia:_ <br /> COMMENTS: �f�$Y_nu( rILI loo • AkP .9 aGP <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:MHEGK ALL THAT APPLy1 <br /> _9 #OF WE�L(S)T713 DESTROYED fZ OVER-BORE DIAMETER OF INCHES TO DEPTH OF-� 7�FT <br /> W IDs: G1Al I ft ? /❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS'44,A COM IN 2 0 �trk]EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:KAUGERS ❑HOSE ❑PIPE JOL 'Q MUSHROOM CAP AT L>3 FT) FTSELOW SURFACE <br /> COMMENTS <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,and all applicable Cali laws. J <br /> Signed 2 /- Title/Company / C— / <br /> Print Name J P 1/61/6 a 0:/'' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS /V oyV I D W 145/d <br /> WORK PLAN DATED -Z.y-1 <br /> APPLICATION ACCEPTED BY J• 0PKK W1DATE fl.Li R <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATES LIZ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIO NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> (y REQUEST PR# <br /> l�Z $125x �-�O (U�a-7 Q1 . X30-/2 SR# SkkJG !�0 <br /> 3*7 orr< sz3 12 R o0 <br /> Gz� PR# <br /> 2900 <br /> 0-57 r/ WC ✓ WAIVER CI[q, C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT L ENCROACHMENT DOCS <br /> EHD 29-01 5109/12 WELL PERMIT APP <br />