Laserfiche WebLink
SAKJOAQUIN Environmental Health Department <br /> COUNTY - <br /> Greatnet s grout here, <br /> SITE MITIGATION 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 /> 48 Hours Advance Notice Required For All Inspections <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br /> This application is made incompliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address #1&f�x� © CitylStatelZip Lie) ,� C� Phone 901 <br /> Cross Street foe r-k 16± APN <br /> Property Owner* C At, _Phone <br /> Address b_ i N A _Q_ CitylStatelZip I -CldL C PH 51940 <br /> C-57 Contractor e% L License# Phone <br /> Address CitylStatelZip q-`33z3 <br /> ConsultantlSub-Contractor License# Phone <br /> Address C itylstatelZi p <br /> CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> ❑ EXTRACTION(Vapor/Water) ❑ HAMMERiDRIVEN DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTTTEVEL WELL CASING DIA <br /> ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> ❑ SUL BORING ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑Yes ❑No Boring Dia: Casing Dia: Casing Depth: <br /> ❑ INJECTION(Air Saarge.Ozone} ❑ HAND AUGER GROUT SEAL DEPTH TREMiE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑ OTHER ❑ OTHER; GROUT SEAL PUMPED? ❑Yes ❑No (Nofe:Maximum Freefall Depth is 30 Ft) <br /> WELL/SOIL BORING IDs GROUT SPECIFICATIONS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) �q�,,1y e <br /> #WELLS TO BE DESTROYED OVFR-BORE DIAMETER of r inches to depth of�gS feet <br /> WELL IDs KPRESSURE GROUT To depth of feet below surface _ <br /> GROUT SPECIFICATIONS ,EXPL051VE5 From mto feet belowsurface(Ilis IDS ("J5) <br /> TREMIE TYPE TO BE USED .`1� AUGERS ❑HQSE , PI•P�E ❑MUSHROOM CAP ❑3 feet below surface or feet below surface if>3 feet <br /> COMMENTS: SVa WA(/Y1 L 2-4"WA. 2.-4" WX&it,LWI ViW-03 LV� t-2 tVt&6,z i <br /> I- r ''wJ kb�F51 rrW'0►� ( tt W -lob$ I-Cyt 4& il WALW <br /> I ereby certify that I am authorized to complete this application and that the work will be don in accordance with <br /> _ San Joaquin County Ordinance Codes and Standards,and all other applicable Cal rnia haws. <br /> Signed Title/Company -F(IQr ��(UI(fy L� <br /> Print Name (r itX Date YnaMk 2 l . 7h'Ll <br /> DEPARTMENT USE ONLY �"� <br /> Application Accepted By: Date Issued: <br /> Grout Inspection By/Dates: <br /> Destruction Inspection By/Dates: <br /> Facilit lSito Information <br /> FA Name FA Address FA# PR#7 <br /> FA PIE WP Reviewed By Wcrk Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Worker's Comp Waiver ❑Encroachmenl Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV D BY DATE WELL PERMIT# INVOICE# <br /> Permit $152 x <br /> 1868 F. Hazelton Avenue I Stockton, California 95205 ! T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> EHO 29-01 05-01-17 Site Mitigation Well Permit Application <br />