Laserfiche WebLink
�•� � - 0 � RECEIV <br /> �°"--tet • SAN JOAQUIN COUNTY � '� <br /> mp <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ENVIR01M1�R TN <br /> �4•• .`.::"ta P- Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:Aww,sIqov-om/eRffRME <br /> FOR <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 SanJoaquinCounty Environmental Health Department. RO W <br /> Property Site tion YJ�I QL[{�l CICy Cross Street 1Qtl '1�14`Q 1,0604 City $}pCKtDy1 Zip APN Q— <br /> Owner \ c ' Jit r��pt\ Address b1r-Z&lct K, P rcomn <br /> C-57 Contractor C �- <br /> City 1 ZIP Phone <br /> `GXdt Address -�i�9yJ;t Qmoc Gtr city Ac`v Cb 'U4 Lic�3b'Ilo phone 9!(o-438-5GEI <br /> Consultant/Sub Cntr 6ECADIS Address x000 PP061 5}. 7"R.P city — r i!le Lic <br /> Billable party_ A R44b1-S Address . Su mG Phone 5LC- (05;?-Il <br /> GIS Coordinates:X Y £o0 <br /> City Zip L/ Phone <br /> CONSTRUCTION WORKTO BE PERFORMED <br /> [4 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> I3 WELL IDs <br /> ❑OTHERIDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> LN MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE r <br /> DIA <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS S( Lt n LTITYPEOFICASINNGS G: 0 STEEL JM PVC OMULTI-LEVEL WELLSING OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS (]HOSE PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Pff Yes 0 No(MAXIMUM FREE_FlA,,LL DEPTH IS 30 FT) <br /> _0 INJECTION('a AJr So Wong)❑HAND AUGER GROUT SPECIFICATIONS 5 ��D o(( �Or t l p� C71 C,r I <br /> —0 OTHER: �HI OTHER:_S•ONI(:, APPROX.BORINGDEPTH rT5 Sri" <br /> -. M BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> ll r r CONDUCTOR CASING No 0 Ye^s:Casing Dia: Casing Depth: 11 Boring Dia: <br /> COMMENTS: Qhe U'Q�1' () SCJ Ji �1 — (`Ult-}' S'Pcf.1 J'(i tyl o` ubWC 9L.CVizo -I-/ SLtfta4e <br /> NOTE. OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> ----#OF WELL(S)To BE DESTROYED DESTRUCTION METHOD•(CHECK ALL THAT AppLYI <br /> WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> GROUTS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE ❑EXPLOSIVES FROM To FT BELOW SURFACE <br /> COMMENTS ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE <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 /> Regulatlorz an all applicable California Laws. <br /> Signed �a`eG7I IF <br /> / Title Company�(00jS / 5er>iuP (7QcI0y1S� <br /> Print Name . � <br /> Date l0 —�l- la <br /> !� cc�� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS_ 1"�FAI:rl C w &'y //PLT' J TArKXiTG 50�c.:<Nr�c�we <br /> WORK PLAN DATED (.(. "v T- v <br /> APPLICATION ACCEPTED BY I Yo,9Kucr DATE ISSUED2 ARS J 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REQUEST PR* INVOICE <br /> 9�r $125x I O'f5833r lr--,-,z <br /> pp SR# CJS <br /> RO# <br /> 3500 <br /> PR# <br /> C-57 WCWAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br />