WORK PLANS - Laserfiche WebLink

Home Browse Search

n4 ' SAN JOAQUIN COUNTY 2' ENVIRONMENTAL HEALTH DEPARTMENT ::'�!° '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 44 a Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slcehd.com 6'd SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation -T 6 r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^J, Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. Q� �•�This application application Is made In compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. � Job Address We_ O fetm lk I'N City/Statelzlp 540CL 0A C&I Phone�'S ltGu✓t -,� ' Cross Street W APN /I-4 - asP0- aA .,ems Property Ownert HAt'0n6A KELZ^ir2s ^• ;y J I P Phone BOi- S41-��.7� Address IC (A) G2j&k TepieDv CIlylStatelZip�. f.4e-C' tA'-i U0Lu�,,, $Z C-57 Contractor E� r1 tv ( License# le s{.�C3 �}i O r2XP. / 4�fionff SV- qq - ��! A dress ^ CIlylStatelZipA4 License# Phone Consultan�n � Q � 14ZL> (LP- Address uw Ybl^Jt,��'to C+ city/State/zIp Chico CA 90,4e CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite BoringsANells Require Access Agreements or Encroachment Penults TYPE OF WELUBORING NUMBER INSTALLATION TYPE CONS C 10 SPE •IC S ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH V 7s ❑BOLTED TRAFFIC BOX ❑STOVE PIPE 1 ❑ EXTRACTION(VaponWater) ❑ HAMMERNRNEN DIA OF BOREHOLE ❑MULTIPLECASINGS❑MULTI-LEVELWELL CASING DIA ❑ SOIL VAPOR PROBE ❑ MUDROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER 'F SOIL BORING �r�❑ PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes ❑No Borgg DM: CNIft9 Dla: Cesing Depth: ❑ INJECTION Me em,m eeonel ❑-HANO AUGER GROUT SEAL DEPTH TREMIE TYPETO BE USED: ❑AUGERS ❑HOSE []PIPE ❑ OTHER jet OTHER:_ GROUT SEAL PUMPED? ❑Yes ❑ e:M um Fr Ihh30 1 n WELD BOIL BORING IDs �R- 1 .F1... S0.. to GROUT SPECIFICATIONS 42, `_(- i - n /I DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD, (CHECK ALL THAT APPLY( #WELLS TO BE DESTROYED [I 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 ❑3feel below surface or feel below surface if>3 feet COMMENTS: I hereby certify that 1 am authorized to complete thia application and that the work will be done In accordance with �j �/ L San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed Alaa ¢l1G�B9g Title/Company Office Manager FCA Print Name Kpnnpth Conk for EC /A Date 4/16/24 DEPARTMENT USE ONLY �Application Accepted By: di Date Issued: 4— Grout Inspection BylDates: Destruction Inspection By/Dates: Facilil /Site Information FA Name FA Address IFA# PR# FA PE IWP Reviewed By I IWork Plan Date G57 ❑C-57 Auttwize0on for vier to Sign Pemut ❑wmWscomp ❑workeescanpwover ❑Emoaclvnenl Permit ❑Access Agreement ❑LeadAgenc/Approwl MFR COM E ICONDITIOIIts- v A t t�p`Q�7L LJ 7 LY. 0 0.S Q 6KQ- " H vor, 0� � 2, SR TYPE PE Sc FEE IN AMT REMITTEI&I CHECK#I RECV'D BY ATE SERVICE REQUEST# INVOICE# W wk-Plan Permit 4oy 3Ij : ' Ig 4 004 EHD 29-01 6-23-2015 l ` 00 ZZ Z Li- h J�6g �S Site Mitigation Well Permit Application