SR0085478 (2) - Laserfiche WebLink

Home Browse Search

RECEIVED SAN J O A Q U N Environmental Health JA0jMa gent -aP ----- - COUNTY - - ENVIRONMENTAL HEALTH rPERMIT/SERVICES `�.''trFoaa�P Greatness grows here . SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections 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 9A 115 . 3 , and the San Joaquin 1115 �County �W/elll�Standards. Job Address ��n YY\ hL IlY(�j City/Sttate/Zip �w a � � NJ C4 P one vim ` �� Cross Street `�>°e , � � � APN Property Owner" [?�' t�j1� C//iTDN /� I� _ Phone `�'�A194(p - 0 � (p Address l i�,� W* i 1� 6 � tJ S 1 CitylStatel2nip� ' C/ qL3 C-57 Contractor tAl2 1 /1'� — I f\)(, License# qO(.e q Phone JWI (ouf 3(/�0 Address A r;7r �� City/State/Zip 11 k 11 LD Consultant/Sub-Contractor rG LJ L.,TrN4oA4gmnse# Phone 51l% ' < WJ 3034 Address I� II j� � PC `�t ( � ; (� City/State/Zip 0 A I CONSTRUCTION WORK TO BE PERFORMED: "Note : Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH ❑ BOLTED TRAFFIC BOX ❑ STOVE PIPE ❑ EXTRACTION (Vapor/Water) ❑ HAMMERIDRIVEN DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUD ROTARY CASING THICKNESSr�y "&N' TYPE OF CASING: [I STEEL [I PVC ❑ OTHER [IC SOIL BORING ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING Yes o Boring Dia: Casing Dia: Casing Depth: INJECTION (AirSoame. ozone) [I HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS .HOSE ❑ PIPE ❑ OTHER OTH R GROUT SEAL PUMPED? Q Yes ❑ No (Note: Maximum Fr fall Depth is 30 t) WELLISOIL BOPoNGIDs � Gt ' F GROUT SPECIFICATIONS � ypQ� � II � ��l1l � lN2l1 C� 10 �1 c 'i5 llrn S tit DESTRUCTION WORK TO BE PERFORMED : DESTRUCTION METHOD : (CHECK ALL THAT APPLY) # WELLS TO BE DESTROYED ❑ OVER-BORE DIAMETER of inches to depth of feet WELL IDs ❑ PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS ❑ EXPLOSIVES From to feet below surface TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP ❑ 3 feet below surface or feet below surface if >3 feet COMMENTS : I hereby certify that I am authorized to complete this application and that the work will be done in accordance with it Tn'Joaquit County Ordinance Codes and Standards, and all other a plicable California la s. L Signed �� Title/Company Print Name Date 1 '�!'! DEPARTMENT USE ONLY Application Accepted By: 1 i Date Issued: Grout Inspection By/Dates : Destruction Inspection By/Dates : Facili /Site Information FA Name1 , I FA Address 0 FA# � ,)� �--� • PR# FA PE 2 0 WP Reviewed By ?( Work Plan Date 3 co )LF �L I 11 ❑ C-57 G57 Authorization for Other to Sign Permit ❑ Workers Comp ❑ Workers Comp Waiver ❑ Encroachment Permit ❑ Access Agreement ❑"dead Agency Approval 17415R COMMENTS/CONDITIONS : WP TYPE PE SC I FEE INFO JAMT ,REmirrEDI CHECK# I RECV'D BY I DATE I WELL PERMIT# INVOICE# Permit S 3 j 3 1$ 152x >3 C W I I I L 1 1r-� COb #3i 1868 E . Hazelton Avenue Stockton , California 95205 1 T 20946 &34201 F 209464-0138 1 www. sjcehd . com EHD 29.01 09-01-17 Site Mitigation Well Permit Application P X03 5 3 A' / 5w" J tqq 2.7 i1a �. - � 1 / 9 101 50E!�Vz v 7L