WORK PLANS - Laserfiche WebLink

Home Browse Search

r SA .� OAQ U I N Environmental Health Department wi't`. COUNTY c 1rr��,•" G(calness grov s here. SITE MITIGATION WELL & BORING PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 24 Hours Advance Notice Required For All Inspections CALL (209) 953-7697 For 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 9-1115.3, and the San Joaquin County Well Standards. Job Address 15Z-AlE City/StatelZip _S r/r7c� lour , C4 !S" /? Phone Cross Street ('d c u m n/ eS -X APN p (o6 -OS-0 - oZSCJ -Goo Property Owners 44C- Phone Address 014ri City/State/Zip�5�c�,�r� �- Chi 95.21�i C-57 Contractor &),, - k,/, / dssaclr- s License# 9S`i YG / Phone 9/6 37,I-/Y3cJ Address Q, 9/ ,/t�� - ConsultanUSub-Contractor Address License# City/State/Zip Phone 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/Waler) ❑ HAMMERIDRIVEN DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA ❑ SOILVAPOR PROBE ❑ MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER "IG — ❑ PUSH POINT (GP/ CPT) CONDUCTOR CASING ❑ Yes ❑ No Boring Dia; Casing Dia: Casing Depth: _jA--W4t ❑ INJECTION (Air Spam, Ozonal ❑ HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE -4�OTHER I,@ OTHE%6q .GROUT SEAL PUMPED? ❑ Yes ['No (Note: Maximum Freefell Depth is 30 FI) ✓WELUSOIL BORING IDs AMT REMITTED GROUT SPECIFICATIONS CCirrr.v� a.od u�cr DESTRUCTION W TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) If WELLS TO BE DESTROYED Permit ❑ OVER -BORE DIAMETER of inches to depth of feel WELL IDs $152 x r ❑ 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 feel below surface or feet below surface if >3 feel COMMENTS: ('„ e (amW 4- Qn Vj FC)0gizaq -4r— Y*-,-( 1'10y\ Signed_ Print Name Application Accepted By: 7 Grout Inspection By/Dates: Destruction Inspection By/Dates: Facilit /Site Inf rmati prized to complete this application and that the work will be done in accordance with V Ordinance Codes and Standards, and all other applicable California laws. ,e Title/Company CL=CJ rA �d/�ca -kt�%i I { A.Tnrt4 i r Date 3 - /S-- Z Date Issued: /`%,oa FA Name (' S ✓i1 G11 FA Address s�„( D *A ;0 I FA# 0 02- gPR# j FA PE WP Reviewed By �� Work Plan Dale -57 ❑ C-57 Authorization for Other to Sign Permit ❑Worker's Comp ❑Workers Comp ver ❑Encroachment Permit [I Access Agreement [I Lead Agency Approval MFR —L -C-- COM ENTSICOND� ITIONS: j 1 G� f ft p � � C� i , �— J r j ' c tit �jtf'1 �` WP TYPE I PE I SC I FEE INFO AMT REMITTED I CHECK# I RECV-D B I DATE PERMIT# INVOICE# Permit 2q0 31_51$152, i ?� $152 x r '' �pWELL W` 0 b' , Z?—3j Cm�,'r W f'Z-" �-b15-?` . SQoo g-" (OS: '1868 E, Hazelton Avenue Stockton, Ca t ornia 95205 209 468-20 1 F 209 464-0138 www.§�gov.org/elid EHD 29-0106-28-21 Site Mitigation Well Permit Application