COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

FILE COPY SAN JOAQUIN COUNTY - y ENVIRONMENTAL HEALTH DEPARTMENT LOP `I 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION q'�� °° P Telephone:(209)468-3454 Fax:(209) 468-3433 Web:www.siaov.or-1/ehd UNIT IV LIFp RC, WELL & BORING PERMIT APPLICATION Ci • r 61_r FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION r 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,. 4 � ICross Street SQ,171'1"c1 F' C- City—TMCIA Zip 15-37& APN C G Property Owner ! Address � -50(1 is Y �U.V14 2& 1Q1 . City Zip OY5 7 Phone'WO9 93 C-57 Contractor lf� Address �J City Lic 906}�94 Phone 53o-&&1-36n'-' Consultant/Sub Cntr-4Vh EL Address2jo(jA)a�1I%n$f*4!fl City Lic Phone p510-&63-913 A Billable Party6lraA int)ff TT to Address Un, ity�� Zip q�/s�3 Phone/ 7�D-4,0'37 GIS Coordinates:X 3*-x' ! Y_W.�Z.46 CgWNSTRUCTION WORK TO BE PERFORMED: NEW WELU13ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OT SOIL BORING IDs ��T.t .FAST-2. E �VS FST �Y� ❑WELL IDs ❑OTHER IDs SOld ��([ 1 Y44 TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE `�!� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: C _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER I ❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL — TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE 1&KSOIL BORING PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes X No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION q.e.AirSoarae.Ozone HAND AUGER GROUT SPECIFICATIONS TGOQ 21L ��IA C.GW'eV"y _❑OTHER: /////❑OTHER: APPROX.BORING DEPTH O'tS r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASINGXNo❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: % e,. NOTE: OFFSIT ELLS& BORINGS REQUIR ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF Fr WELL IDs: ❑PRESSURE GROUT TO DEPTH of FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO Fr BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L3 FT) Fr BELOW SURFACE ` COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,rd all applic le Calif is laws. Signed l Title/Company /// ILI Print Name jai C k Date DEPARTMENT USE ONLY a v 2-f 466 SITE MAP IN UNIT IV FILE-SITE ADDRESS Il0j. cz,� i7 loC WORK PLAN DATED � APPLICATION ACCEPTED BY DATE ISSUED r!O AREA 610 lk GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC># PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQU/E�S/T- PR# �QOS $12.5. IzS Z SR# Z-gco -3 1"4 375 � 20o aSt C-57 V WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC - EHO 29-01 07/28/10 �// WELL PERMIT P