COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

NUMBER INSTALLATION TYPE ID HOLLOW STEM CI HAMMER/DRIVEN as CI MUD ROTARY ID PUSH POINT (GP/ CPT) X HAND AUGER CI OTHER: TYPE OF WELL/BORING ID MONITORING 1:1 EXTRACTION (Vapor/Water) X SOIL VAPOR PROBE CI SOIL BORING 0 INJECTION (Air Spam. Ozone) o OTHER WELL/ SOIL BORING IDs SAN JOAQUIN COUNTY Greatness grows here Environmental Health Department RECEIVED SITE MITIGATION WELL & BORING PERMIT APPLICATION:RoNmEEB ON6TAL20H1EAL8 TH For Wells and Borings Used for Contaminant Investigations and Remediation PER NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E 48 Hours Advance Notice Required For All Inspections MIT/SERVICES 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 San Joaquin County Well Standards. Job Address 515 W. ckv_ir ‘44-1 City/State/Zip STo0(70^/ C_' Cross Streets ' C. pt ilk ri t r 10^..1 V . 1..-1.A I $ 4 S+- . APN 19.7 -#3 .74- oe Property Owner* D oAfrizo An filer I Address 11 4:‘,3 0 CO*, Ili Vhine% A o pki) City/State/Zip /A,A.041134 C-57 Contractor ,, AdvAmt, 0 G. Address EA %gra" rAt" SKI &.37 SINAv./ °Ar o City/State/Zip SI ti tir. To pi Consultant/Sub-Contractor Address City/State/Zip II II CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits SA0.1. A's A. bik4 t. License# Phone 115- 4\1•1-5 7 84 Phone 7 eite Ta`l -s-en S13 CZ 49 MO 1 6 0141 License# bko Z.Z1 Phone SAAPA AS ArtiO4e Phone SA A^4. 4 S A-17041 CONSTRUCTION SPECIFICATIONS BORING DEPTH • r liSliciOLTED TRAFFIC BOX El y r i 12 STOVE PIPE DIA. OF BOREHOLE ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA CASING THICKNESS TYPE OF CASING: CI STEEL CI PVC CI OTHER CONDUCTOR CASING CI Yes No Boring Dia: Kilt Casing Dia: 0,#/)A Casing Depth GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE CI PIPE GROUT SEAL PUMPED? 0 Yes; AN: (Note: Maximum Freefall De t 30 Ft) GROUT SPECIFICATIONS Ps IAA" T i p t ,I 4 DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 0 PIPE 0 OVER-BORE 0 PRESSURE GROUT 0 EXPLOSIVES 0 MUSHROOM CAP DIAMETER of inches to depth of feet To depth of feet below surface From to feet below surface 0 3 feet below surface or feet below surface if >3 feet DESTRUCTION METHOD: (CHECK ALL THAT APPLY) COMMENTS: I hereby certify that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards, and allther applicable California laws. Title/Company 40 ;U.. T ot NA't Crti- / A c . E. Print Name 1,I\ Cq E *4 r Date 0/.. -ei V -. 2,0 t• r Application Accepted By: Grout Inspection By/Dates: DE7TMENT USE ONLY • Date Issued: 5-e-t vr*wikk," Destruction Inspection By/Dates: Facility/Site Information FA Name ...--- 1 f cvv.1 or, t cc., .., .,.‘ c.:ito .,.. FA Address cic v„./ (-2A-4,/,4-1,..- vici FA# 0 0 1 si--4, PR# ocz_ 7 rici FA PE - c . 0 WP Reviewed By L '-')( Work Plan Date Li I ,." I ' 1:1 C-57 I2K-'57 Authorization for Other to Sign Permit EKOrkers Comp CI Workers Comp Waiver CI Encroachment Permit CI Access Agreement Er-Lead Agency Approval [04R COMMENTS/CONDITIONS: WP TYPE PE SC FEE INFO y. AMT REMITTED CHECK# RECV'D BY DATE WELL PERMIT# INVOICE# Permit )5910 't -5i 5 1.-- $152x pr j Z. A 3'0 ,.{ -z,jii, i.. - Y 1.11-tklig Ofcc000-t‘ 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application L5(‘'' 'TA t)-1 “1-4 01 CO— Signed hAN t.t,5-1-1 3