Laserfiche WebLink
o ut.N•.e SAN JOAQUIN COUNTY AL <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> ' ' • 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209)468-3947 Fax:(209)468-3433 Web:www.si9ov.orn/ehd UNIT IV <br /> eq�ii=oR-.�c <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 San Joaquin County Enviro mental Health Department. Q 2 <br /> Site Location �0 r'�4 Cross Streelt l��iLY(� QttV� City/State 5�� h Zip APN �7+ V�� —0 <br /> OwProner f % t7 Address !3f'2 P /1 Ve City/State ,�eS o Zipq!535(o Phone `t q4/ 99713 <br /> C-57 Contractor Address 3�et 6-"�P City/State" " Lic N O Phone 9/6.�n3g. 11 by <br /> Consuitant/Sub Cnt Address `Isa Cj7k,., �10�1,yP 51,*Wity/State Lic Phone 9/1,. 185.2-O <br /> Billable Party Address City/State Zip Phone <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ARCADIS <br /> ❑SOIL BORING IDs ,r <br /> ❑WELL IDs Infrastructure,environment,facilities <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICAT BRETT KREHBIEL <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑I Scientist 1 <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS <br /> _❑SOIL VAPOR PROBE [IDriv <br /> MUD ROTARY DEPTH OF GROUT SEAL ARCADIS Inc. <br /> 950 Glenn Drive,Suite 125 <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes E Folsom,CA 95630-3130 <br /> _❑INJECTION r,.e.Air Sparge,Ozone)❑HAND AUGER GROUT SPECIFICATIONS Tel 916.985.2079 x14 Fax 916.985.2093 <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH_ Email brett.krehbiel@arcadis-us.com <br /> CONDUCTOR CASING❑No❑1 <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> ADESTRUCTION WORK TO BE PERFORMED: �1/(Ut/— DESTRUCTION METHOD: CHECK ALL THAT APPLY T� <br /> #OF WELL(S)TO BE DESTROYED / OVER-BORE DIAMETER OF Q INCHES TO DEPTH OF ' FT <br /> WELL IDs: M/— WI— W— kI`� 0 0 PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS i ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Lj AUGERS ❑HOSE --.�1p,)J MUSHROOM CAP AT(>3 FT) 5 FT BELOW SURFACE <br /> COMMENTS ' r r 6 M <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap cable California I <br /> Signed Title/Company � t�ftBrr�O{ <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> r <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTEDBY- / DATE ISSUE / AREA <br /> GROUT INSPECTION BY(/ FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> Sd 125 X 7 o�TSGY� 3 X37 / SR# <br /> 37� <br /> 00 �/�� 3 00) <br /> PR# <br /> X900) <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />