BILLING/PERMITS_2017-2018 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY r - z ENVIRONMENTAL HEALTH DEPARTMENT 1868 Hazelton Avenue, Stockton, CA 95205-6232 4�tFOR� a Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov.org/ehd LOP SITEION i �. WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION pr % '. 1 20y t ¢/ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAP4Jn;a FI,Vu,� �'' C Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made 4q�plf8holi,, Py Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. CC'r-4,r,' Site Location 17100 Murphy Parkway Cross Street D'Arcy Parkway Lathrop, CA Property Owner ASP/RWM Properties, et al C-57 Contractor Cascade Drilling Consultant/Sub Cntr Brusca Assoc., Inc. ZZZ•=rS L I V 1 r'1Cj;>frrq Address�Hee-a Address 3000 Duluth Street Address PO Box 332 `Billable Party Brusca Assoc., Inc. Address GIS Coordinates: X 37.806 y -121.287 PO Box 332 ^X , Clty/State Zip 95330 APN 198- 12-009 Lt -C (F City/State ens /CA Zip g4;32A Phone 1925) 674-8400 City/State West Sac., C/Lic 938110 Phone _(916) 638-1169 City/State Roseville, CALic CEG#1948 Phone (916) 677-1470 City/State Roseville, CAZp 95661 Phone (916) 677-1470 OC- - 3+tc-. 3 S RiSRot l SZE? It- Fv�L• C14ARit&:� O "L L ,%1 1- PE lZ M.T i r _TN/ 1, A.Au\ -nv e:CWI -PT.. ❑ NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) ® SOIL BORING IDs B1, B2, B3, B4 and B5 PE CODES ❑ WELL IN AMT REMITTED CHECK # ❑ OTHER IDs DATE SERVICE IRO REQUEST TYPE & # OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE 2" ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE 5 ® SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) _❑ INJECTION (Le._ rawroe ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Boreholes to be completed grouted with neat cement _❑ OTHER: ❑ OTHER: APPROX BORING DEPTH 15 ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE Direct push borings CONDUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE 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 FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 1 hereby certify tPat I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, anplell apoll):able California laws. Signed _ Print Name SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY C GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: Title/Company President/ Brusca Associates, Inc. Date 3/27/17 DEPARTMENT USE ONLY DATE ISSUED FINAL INSPECTION BY DATE AREA DATE ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE IRO REQUEST # PR# INVOICE SR# S`� Olj 2l /7 3500 C 57 %Av PR # 2900 EI-IDii-01 5/09/12 LC I 1 tK Or AU I HORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP