WORK PLANS - Laserfiche WebLink

Home Browse Search

SAN :.JOAQUIN Environmental Health Department I . -COUNTY L' 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 its made in compliance with San Joaquin County Development Title,Chapter 9-1115I.3,and the San Joaquin County Well Standards. Job Address I 'r7 .. S . CltylStatsIZip S`40 ICToy CA 95201 Phone `L0cI i- I?-PPY Cross Street APN 122 Property owner Ct Hof 5`t-oc D� i41-tz— olio Phune2y`r- W -5D39L Address oN1�l` 'I! ! r Otur- clty/State/zlp 4-OJ e• Ck C75ILL G 1n C-67 Contractor 01 TRa, sl1 !Mi License# -7-06 6 K Phone-7l6 - �53 -SOLD Address 113SD HOwi(/ 61ir /r(t t e City/StatelZlp (ZC.s4e Cpr o" gS7 Lf'L4, , `/ c ConsultanUSub-Contractor m,f Oh y (u1�/" r Z•� • License# A 9 A 1 SZZ�-S 1 Phone cr-pryp-S53J Address2�_ O9 cly}M. Ave. . Sti;T`! 0,D citylstateizip <n,rs.l. CA- "I'll CONSTRUCTION WORK TO BE PERFORMED:-Note: OUsite BodngsNVelis Require Access Agreements or Encroachment Permits TYPE OFWELUBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑ MONITORING ❑ HOLLOWSTEM BORING DEPTH b(BOLTEDTRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporMela) ❑ HAMMER/DRIVEN CIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVELWELL CASING CIA 9SOILVAPORPROBE -2� ❑ MUDROTARY CASING THICKNESS N— TYPEOF CASING: [I STEEL ❑PVC ❑ OTHER ❑ SOILBORING PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes)4% Berig Die: Casing Die: pang Depth: [I INJECTION Mireevm.evome []AUGERSHANDAUGER GROUTSFALDEPTH TREMIETYPETO BEUSEO: AUGERS ❑HOSE PIPE ❑ OTHER ❑ OTHER GROUTSEAL PUMPED? ❑Yes ONO (Nora:Mmiinun FreelaO Depth is 30 F0 WELL!SOIL BORING IDS GROUT SPECIFICATIONS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:ICHECK ALL THAT APPLYI #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of_feet WELL IDs ❑PRESSURE GROUT To depth of_feet below sudace GROUT SPECIFICATIONS [I EXPLOSIVES From_to_fiethelmsurhce TREMIE TYPE TO BE USED [I AUGERS [I HOSE ❑PIPE [I MUSHROOM CAP ❑3 feel below surface or feet below surface 9>3 feet COMMENTS: I hereby,codify that I am authorized to complete this application and that the work will be done in accordance with aa � /pguln County Ordinance Codes and Standards,and all other applicable California laws. Signed "A Title/Company l`' ttiiu Yr1 c1 �4M Gr l/ �'tJT.. SDlvl-ilJ Print Name it roV it Date b--LI -Zol a / DEPARTMENT USE ONLY Application Accepted By: a raw Date Issued: Grout Inspection By/Dates: Destruction Inspection By/Dates: Facill /Site Information ��..// FA Name FA Address /yfS• J✓fk- de FA# �Zi.!' ,3L9 PR# Q,S J / FA PE =9�p WP Reviewed By I dtvs— work Plan Dale ❑C-57 G57Aubodrallon forOlherto Sion Pemik ETWoritersCOnne ❑WoacefsConp Waiver GdEncoactivinantPernit ❑AoeessAgreement Plead Agency Appuval ["FR COMMENTSICONDITIONS: 7%� /Awole ...•- g,P.% J.RI y42;,V L /;ir440 calf.-- "Q ajj�' 1b b•C td 40 d-soy.d �YVL� PiT/D yi. R," ` �V/ WP TYPE PE I SC FFEEINFO JAMT REmiTrEDI CHECK# I RECV'D BY I DATE WELL PERMIT# INVOICE# Permit 2 WI 1313 s152X 2 ,p U I, 9=174y0 , 4 397610 186E E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com EHO2 l 0e0147 Site Midgeeon Well PBnnl1 Application A70A'Pla — Zfe3 Si-3 -#/SZx3 a!l Nd-$icn /69•' A*4 wl-/ g-"1P JOev V767