Laserfiche WebLink
AauVlry SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />a:. < <br />•':'�'" 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br />/Fol[i�;p Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.orct/ehd <br />LOP <br />SITE MITIGATION <br />UNIT IV <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, a d the Standards of the San Joaquin County Environmental Health Department. <br />C <br />. ,,✓Py am <br />L/ <br />Site Location Cross Street <br />��<g�saYb• D6 5',090 06 <br />treet City/State � Zip APN <br />Property r Pwa —SuL/4 7.� 07'/ <br />Owner Cyt �AQ�i� ��~//Address _e1g & iyWZC-z �,4v4ity/State L� Zip, %s�� lone <br />eO;P' '��0 616 <br />C-57 Contractor G}en� zllf' tNdress ism E.QD City/State/j'% j�ELTrc � �11one XIS—ka <br />Consultant/Sub Cntrr �� Address _W �t !/ qty/State �,,%L�i l�VV aa <br />Phone � a �0'—?,f% <br />Billable Party,.,Cn?^' 6719Q /� & "=_re t„¢�ilJ'0!" .City/State S� ''Zip aJ% Phoneme �Gp <br />GIS Coordinates: X Y �� <br />CONSTRUCTION WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) <br />SOIL BORING IDs <br />WELL IDs <br />OTHER IDs <br />TYPE & # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSkA <br />MONITORING f�HOLLOW STEM DIA. OF BOREHOLE �A"ULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA: <br />_E1 EXTRACTION: Vapor/ Water /❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL NPVC ❑ OTHER <br />_❑ SOIL VAPOR PROBE '),MUD ROTARY DEPTH OF GROUT SEAL// TREMIE TYPE TO BE USED:,$ AUGERSl? HOSE [I PIPE <br />_❑ SOIL BORING El PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: Yes ❑ No(MAXIMUMFREE FALL DEPTH IS 30 FT) f <br />_E1 INJECTION (i.e.AirSoarae. Ozone) [I HAND AUGER GROUT SPECIFICATIONS 'W6T! <br />_❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH /,r ❑ BOLTED TRAFFIC BOX OR119STOVE PIPE <br />�LG G� % �Q CONDU TOR CASING []_No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: <br />COMMENTS: S�f%il �i�� f!/TE .• <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 pre ; his application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all ap lica I' a ' ornia laws. <br />Signed Title/Company eOUAI <br />Print Name <br />L✓ /y!/ L�i9 �G �A9�i242 Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS <br />WORK PLAN DATED 7 <br />APPLICATION ACCEPTED BY IU r;q- z s X73 /3-4 r 'wl DATE ISSUED ��_� 43 AREA <br />GROUT INSPECTION BY FINAL INSPECTION BY W�LrY .DATE 3, /3 <br />DESTRUCTION INSPECTION /B�Y DATE <br />0 <br />COMMENTS/CONDITIONS: +1P . Wr Zt-e-A_-. C •- /0 N 6.O•n� /6/ /^T <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />SERVICE <br />I RO # <br />INVOICE <br />REQUEST <br />PR# <br />li�l7/ <br />�d�7 ® <br />; <br />I� <br />$125x <br />SR# 6"7f'7-0 <br />56WD D <br />RO# <br />(3500) <br />PR # <br />(2900) <br />C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 29-01 5/09/12 WELL PERMIT APP <br />