COMPLIANCE INFO_FILE 8 - Laserfiche WebLink

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,..,r,,,r,F,•.�� SAN JOAQUIN COUNTY '`~ = ENVIRONMENTAL HEALTH DEPARTMENT LOP { 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATIONUNIT IV • �j`R� - Telephone: (209)468.3454 Fax: (209) 468.3433 Web:www.sIgov.org/ehd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location -4Z'O f=aSr (ON Sr Cross Street �T1'AL.�6 ►�1 VA city�—Zip °153 APN �'y I'oiq Property � — Owner,�(1tal[P,aC-;' *C, 1ci*11n4ddress g491 At&SMSt $��ity _QASCVIkkA Zipg�TI Phone %' O!'04 C-67 Contractor PeneCw1r, Address 1151 AhCe St, $ lCA City 1a Lic 7MVI Phone 5�0'{tr(ol'310C't Consultant/Sub CntrAAAIJI.S Address 110RO Rt ,&t i0y 1 LicI Phone 11 �gte' I$31 Billable Party hRL pl& us Address loco City Ip_8o1Z9 Phone GIS Coordinates:X 37,?�_Y -/z/-,q r5 a CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING 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: ❑STEEL ❑PVC ❑ OTHER O _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yee ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) rn _❑INJECTION(I.B.Air Sparse Ozonel❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑Yee:Casing Die: Casing Depth: Boring Die: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECK ALL THAT APPLY 9 OF VVELL(S)TO BE DESTROYED OVER-BORE DIAMETER OF Wt101iNCHES TO DEPTH OF ct h014A WELL IDs: nth%C*WA -habU ❑PRESSURE GROUT TODEPTHOF FT BELOW SURFACE GROUT SPECIFICATIONS o+ " 0 EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:LJ AUGERS LJ HOSE PIPE ❑MUSHROOM CAP AT L3 FT)_ FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby cert) that I have pr application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulatlo s, nd all appilcabIlornia Laws. n Signe r — jp�cltthis lfir - Title/Com t fo`PciPrF.st1�lf(2-CI�P,7:S Print Name Date (/ �7 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS / �U C• C� S� WORK PLAN DATED APPLICATION ACCEPTED BY J. y0/9XU rn DATE ISSUED I! /O -1( AREA !6 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE _ COMM ENTS/CONDITIONS; ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST -PR*-- \� agog $125.8p SR# G � 5 Zoe Z hT PR# 2800 C,-- q9 �•T J qc) C-57 VVI, _WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC