FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

FILE COPY o,a...n SAN .JOAQUIN COUNTY ? ENVIRONMENTAL HEALTH DEPARTMENT LOP < SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 \ UNIT IV! Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:wWw.siqoy.org/ehdhd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tottNc;4 r i�LtYr:Cl Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application its made in co`pliaace with SannHc LL Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. SN00.5(06,Kio4S, aSr5i5 541A;5'� - C� o� APN tog 3Di3 tca 3�Z6. Site Location.�� Cross Street ' R0Aiw Yt�,d- City S.nru-roN Zip 15 Z Property —r n� Owner 5-* E. '[�t65 A✓o L5Nt lAtfS Address 5}6-1 ACIELe'AVE�lZO City 51dr,,c To:) Zip rj Phone C20)NSB-1 91 C-57Contractor �'1Qal,( L��iV�a..c} Address 550 M4wZ 47-66 City MAAT-1�JEt Lic 51 Phone (9ZS)3I3-i8� ConsultantlSub Cntr CiF-occrJ Address )2jjtl ¢� QI-'a�� City JA,.<+ 6aeo�,A Lic Phone Miti)SSZ-4{1C Billable Party �^r E,,r.' Address 31(.nC, -�UAke4 Da.080� City 'AIM- *Cntlk,& Zip 95}4Z Phone (kIG)8it 4/I GIS Coordinates:X 3zwo Y -(21 31` CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ur) ❑OTHER IDs ..0 TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE CI) _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION r..Ar Soama Ozonel❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth'. Boring Dia:_ COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ` DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD'(CHECK ALL THAT APPLY #OF WELL(S)TO BE DESTROYED U OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT LL IDs: SGS °i�ti "'� IR PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS "64r Frn�N-r E]EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED:IX AUGERS ❑HOSE ®PIPE ® MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS r-W-SE« T — 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS T 1 hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin County Ordinances,Rules and Regulations,and alLapplic le C;.4fornia Laws. Signed _ iii /�� Title/Company GCCN .,wS �rnrv.5 �^r.JScc rJ;ZfFE�meour:ryy; Print Name Date 11411L DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS 1�0 l I 1e f}V E WORK PLAN DATED APPLICATION ACCEPTED BY J- m/dK4s DATE REA k�Q GROUT INSPECTION BY FINAL INSPECTION BY A A,wl ATE ` -dZ DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# INVOICE PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REQUEST PR# $ 125 x I r '`d 125. �a f Gj. ao,e SSIH(z� Z+: l`Iv'' �e�c� 375 �vVtiy Ro3�� r15b zoo) 95;Z02' C-57 WC WAIVER "( C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 'Z--