Laserfiche WebLink
f <br /> �o'P4- t'�o • SAN JOAQUIN COUNTY • FILE COPY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www siaov OrO/ehd UNIT IV <br /> [(PORN <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 Environmental Health Department. <br /> Site Location Afq( ross street City/State } T' Zip �� <br /> APN '/O C)06 r <br /> OwneVTMrni -fin/) LTAn lq� E <br /> "[•-rl 611tti /State ry2,q,,,��� �<2��� <br /> C-57 Contractor ty "-�-L"�`HLip= Phone <br /> UFn nine£ TCtaF Address �d. hOT /it city/State mi, f nL!c /y7Go Phone <br /> Consultant/Sub Cntr Address city/state Lic Phone <br /> Billable Party Address <br /> GIS Coordinates:X 7�� Y �(2l �1v0 City/State zip Phone <br /> CONSTRUCTION WO# <br /> RK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> WELL IDs <br /> OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> LK,MONITORING ,HOLLOW STEM DIA.OF BOREHOLE p ��- /r <br /> 11 12.�i ❑MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS qo <br /> TYPE OF CASING: 0 STEEL APVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL <br /> ,Z—" t TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE XPIPE <br /> _0 SOIL BORING Cl PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes MINo(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _O INJECTION(I.e.ArSoameOzone)0 HAND AUGER GROUT SPECIFICATIONS r T /' <br /> _0 OTHER: 0 OTHER: APPROX BORING DEPTH ['� b <br /> ❑BOLTED TRAFFIC BOX OR 0 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 /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METH Di(CHECK ALL THAT APPLY) <br /> �_#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF F7 <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF <br /> GROUTS ❑EXPLOSIVES FROM FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE To FT BELOW SURFACE <br /> COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 1 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,an all applicable California laws. <br /> Signed Title/Company <br /> Print Name '(' l/ �' d6f <br /> Date Z 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS IZ DO 1 v <br /> WORK PLAN DATEDtf(,.tc 7a( r - <br /> APPLICATION ACCEPTED BY j- YO 6K"-' DATE I <br /> CIO <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION By <br /> TE S Z?•I Y <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> a-"^ FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> 2gd� ' REQUEST PR# INVOICE <br /> $4125x7 _ y9n8 eokrv7�2 S-IZ-,Y SR# 4�f(j y I <br /> 3500 <br /> PR# <br /> C-57_J�' WC WAIVER2900) y �� <br /> EC-57 LETTER OF <br /> HD 29-01 WORM —.� AUTHORIZATION TO SIGN PERMITy ENCROACHMENT DOC /V r( <br /> WELL PERMIT APP <br />