Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> UNIT IV <br /> Telephone:(209)468-3147 Fax:(209) 468-3433 Web:www.siaov.ora/eh <br /> WELL & BORING PERMIT APPLICATION <br /> 571V�" 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 San Joaquin County Environmental Health Department. <br /> Site Location 374 Lincoln Center Cross Street West Benjamin Holt City/State Stockton.CA Zip 95207 qpN 9741029 <br /> Property �— <br /> Owner s.a1o.m—, Address 1810 East Hazelton Ave City/Slate Stockton,CA Zip 95207 Phone 209-468-3000 <br /> C-57 Contractor National E.W.P Address 1961 Meeker Ave City/State Richmond.CA Lic 953646 Phone 510-236-6282 <br /> Consultant/Sub Cntr Address City/State Lit; Phone <br /> Billable Parry Geosyntec Consultants Address 3042 Gold Canal Drive Suite 201 City/State """ieCei°°""c" Zip 95570 Phone 916-637-8048 <br /> GIS Coordinates:X 121.321172'W y 38.008905°N <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 WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW$TEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _D EXTRACTION:Vapor/Water D HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 0 PVC 0 OTHER <br /> _Q SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS Q HOSE D PIPE <br /> _0 SOIL BORING D PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes D No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _D INJECTION I. i Spam,Owns)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: D OTHER: APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX OR <br /> ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth:_ Boring Dia:_ <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> .STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALLTHATAPPLYI <br /> #OF WEu(S)TO BE DESTROYED IN OVER-BORE DIAMETER OF se.Tebie INCHES TO DEPTH OF5e2 Table FT <br /> WELL IDs: SeeTebka N PRESSURE GROUT TO DEPTH OF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS Neal Cement(94 lb beg 15-6 gallons water ❑EXPLOSIVES FROM TO Fr BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS HOSE Q PIPE X MUSHROOM CAP AT FT) See Table FT BELOW SURFACE <br /> COMMENTS Tables.eoures.access a0reement attached <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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,Od a_ll app/lice ]a California laws. / <br /> Signed vl���t✓!/�7 — Title/Company Project Geologist Uj l;, g4 <br /> Print Name Timothy Dams ^^ Date 8/22/2014 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS AZ T S'MePtpe <br /> WORK PLAN DATED ..I L(L..`� /h, 20/y <br /> APPLICATION ACCEPTED BY t - BIa�Ctt� DATE ISSUED AREA 4694 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE ROINVOICE <br /> REQUEST PR## <br /> X02 $130X 110 \1 7�j 223352 Gxa,W $•ZZ-lel SR# 70 38"5 <br /> 9v3 AC) 390 _ RO# <br /> (3500 <br /> PR# <br /> (2900) <br /> C-57� WC WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _V_ENCROACHMENT DOC <br /> EHD 29-01 /24/14 WELL PERMIT APP <br />