Laserfiche WebLink
o.• a SAN JOAQUIN COU '�y <br /> �.• � •.o <br /> ENVIRONMENTAL HEALTH o: DEPARTMENT - LOP <br /> .a <br /> 1 1868 Hazelton Avenue, Stockton, CA 95205-6232 W I <br /> ng <br /> V <br /> �4C/FOR�`P Telephone: (209) 468-3147 Fax:(209) 468-3433 Web:www.sjgov.c rg/eh <br /> WELL & BORING PERMIT APPLICATION OCT 14 2014 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 comp lance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the,San Joaquin County Environmental Health Department. <br /> ileo"S-:04 6 1 r--- <br /> Site <br /> -sSite Locatlon•�205 C WtIA Cross Street Ci State—{ ,.v CA Zip APN <br /> Property <br /> OwnerCo1+(-aAS Address tq"}G City/State 4 ,,. (A Zip%'20,5-- PhoneC20r1)q`1�--?Sy's <br /> C-57 Contractor OCOCt1A Address City/State ',rer Lic-7I(o0C7(i Phone(R25)37I-r*qt <br /> Consultant/SubCntr Address City/State Lic_ Phone <br /> Billable Party Address City/State Zipri�Phone <br /> GIS Coordinates:X ?gu12loo Y-171.41io'm 0 U <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WEL 60RING CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> �x SOIL G IDS_ c I 0,A.CL S 9- <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELU@ING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE it <br /> _� ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I.e.Alr Sparge,Ozonel❑HAND AUGER r� I GROUT SPECIFICATIONS <br /> Z IdOTHER:61 t-t r VrOTHER:4rIV-r-+ksk APPROX.BORING DEPTH 2O( ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: Cdlleel:n� SnII r;.,,^Ik At"u,vLaTla/tr �i_�,1�r4Lts rk SZ <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 WELLS)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ElPRESSURE 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 /> 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,and all applicable Cafifor ja�'la s. I/ (� U <br /> Signed � Title/Company V,(T', /-►y / <br /> v � <br /> Print Name zic 6filr Date Cv Vii,/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS e,e+ <br /> WORK PLAN DATED V17 Iq 9 .41 <br /> APPLICATION ACCEPTED BY `(./eJ�@�t DAT AREA <br /> GROUT INSPECTION BY FINAL INSPECTION¢Y ..------•-DATE / 12-1 <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 /> p REQUEST PR# <br /> 2105' $130X J�o 67900 �j la�ZJ !�I SR# <br /> 2 03 3q� 079/y <br /> PR# <br /> 2900 <br /> C-57 V WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 7/24/14 WELL PERMIT APP <br />