Laserfiche WebLink
S301A83S/1Jw83d <br /> H11V3H_1ViN3U4NO8IAN3 <br /> oPa`'t"c .SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT «VG V VL <br /> `•• — 600 East Main Street, Stockton, CA 95202-3029 ITE MITIGATION <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.s' ov.or <br /> WELL & BORING PERMIT APPLICATION ((fi�rr <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIAT&T 2 8 2011 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Owl MFS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is <br /> Joaquin County Development Title,Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health depart {�tt�f'I/5� I EI <br /> Site Location Rindge Tract Cross Street Eight Mile Road City San Joaquin Count,p APN <br /> Property <br /> Owner RD 2037,c/o MBK Engineers Address 1771 Tribute Rd,Suite A City Sacramento Zip 95815 Phone 916-456-4400 <br /> C-57 Contractor Taber Drilling Address 536 Galveston Street City W Sacramento Lic 466270 Phone 916-371-1690 <br /> Consultant/Sub Cntr Hultgren-Tillis Engrs Address 2221 Commerce Ave,#A-1 City Concord Lic Phone 925-685-6300 <br /> Billable Party Hultgren-Tillis Engineers Address 2221 Commerce Ave,#A-1 City Concord Zip Phone 925-685-6300 <br /> GIS Coordinates:X -121.4700 Y 38.0451 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑x NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> Z SOIL BORING IDs Borings 1 through 8 <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _4 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑x MUD ROTARY DEPTH OF GROUT SEAL `50' TREMIE TYPE TO BE USED: IF]AUGERS ❑HOSE ❑PIPE <br /> 8 ®SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i e.AirSoarae Ozone)❑HAND AUGER GROUT SPECIFICATIONS neat cement grout <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH `50 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS`& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT To DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ❑AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT(?3 FT) FT BELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I 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 /> Rgulations, d II applicable <br /> alifornia Laws. <br /> Signed � 1 � Title/Comp any <br /> Principal Engineer/Hultgren-Tillis Engineers <br /> Print Name R.Kevin Tillis Date 'Q/46i1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESSMri <br /> l (C..r Ti�r,.r7r <br /> WORK PLAN DATED tol vt I tl <br /> APPLICATION ACCEPTED BY 411aMlt4 .-- DATE ISSUED AREA <br /> GROUT INSPECTION BY 11N ,,r`.^ FINAL INSPECTION BY DATE 1 I L <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 GPR,�# <br /> q <br /> a C' $125x L toZS O � It �J r� SR# b3D� <br /> RO# <br /> l / (3500) <br /> PR# <br /> (2900) <br /> C-57 WC __ WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />