WORK PLANS - Laserfiche WebLink

Home Browse Search

Is SAN JOAQUIN Environmental Health Department 1. 1isp3 (_: i )UNTY-- 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 ma/de in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. Job Address NA Cltylstateizip VALy. 04 qG"519-4Phone N1A Cross Street faa Gf4P-13A1AwiApd c,&tLta.LT lr)AI& ILA APN ZJDo -020 -9'3 Property Owner'CIT"kr" r c-, {1ZISI4A-fV VLF- Phone Address 6—f- 1,.AaAy I ' . - • clly/staterzip ,A1-o T'�•1 �i Lem �G�- ,R/ I) C-57 Contractor SllZO/4" zM0UV- 615L-P5ACi._f lNe • License# 14'664/03 Phone !�"-404 -66S,6 Address`1.40 GJILLL"90'�J ?. City/State/ZipQ2�33 - Consultant/Sub-Contractor It-ft A S'k,A License# Phoneg41`339-694-� Address�o�e f"L 'T`�"Y,, '2 City/StatelZip e6• LCe' , G,A �'Q01q- i CONSTRUCTION WORK TO BE PERFORMED:*Note: Offsite Bodngs/Wells Require Access Agreements or Encroachment Permits TYPE OFWELLIBORING NUMBER INSTALLATIONTYPE C0 TRUCTB'NSPECIHCATtONS ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 2b Ufa [I BOLTED TRAFFIC BOX [I STOVE PIPE ❑ EXTRACTION(VapmNater) ❑ HAMMEWRNEN DIA OF BOREHOLE [I MULTIPLE CASINGS.MULTVLEVEL LCASIN_GrDIA O •��/'W SOILVAPOR PROBE -MUD ROTARY CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC OTHER 61 SOIL BORING PUSH POINT(GP/CPT) CONWCTORCASING ❑Yes No Bamg Dia: Coung 0ia: CasYgDepih: - ❑ INJECTION W'snama Da,vnt ❑ HANDAUGER GROUT SEAL DEPTH THERE TYPETO BE USED: ❑AUGERS ❑HOSE []PIPE ❑ OTHER —per❑ OTHER: GROUT SEAL PUMPED' ❑Ye ; No (Note:MmdmumF WELUSOILBORINGIDs y s . v2i fii-'� l GROUT SPECIFICATIONS folD •p �Y�`I I TIEA�L�1..1�'ti•- _r T� � DESTRUCTION WORK TO BE PERFORMED: DE UC O (CHECK �1,I ✓PC�ar rl It WELLS TO BE DESTROYED ER-BORE DIAMETER of_inches to depthof feet WELL 1Ds - - - - � ❑PRESSURE GROUT To depth of_feel below surface GROUT SPECIFICATIONS .ct. - ❑EXPLOSIVES Fran_to�feet below surface TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE [I MUSHROOM CAP ❑3 feet bebw slu�decea feel belowsudece if>3 feet COMMENTS: � tt"!�, �EY+� IT Jt(� "'CA• 710" IS I'F-Ty-t�AC r)�7E�-'h'At` INOrLK- W4 2-�u'4'P}G GF/N t �s EP W t"j-r oN 11 1qj( 1 hereby certffy that I am authorized to complete this application and that the work will be done in accordance with San Joaquin County Ordinance Codes and Standards,and all other applicable Cali�ffoorn�ianlar�wss.e. r, Signed _rifle/Company V �� -1 - ►'"• - Print Name \)5'r1V A WAY Date rT �-P PARTMEN USE ONLY ' 20Application Accepted By: Dale Issued: Grout Inspection By/Dates: r Destruction Inspection By/Dates: n LNL FacilityiSIte Information �• u L - e il.+ n 0. 0� FA Name 15 tv fT r lIG FAAddress 1 M4f1 1C l F ©� �J "QLeadApncyApprwI 7-30 FA PE WP Reviewed By Work Plan D❑C3Y ❑C51AuBwr'kwIbnfarOMtoSignPenn' ❑wmefsww ❑W"WsOompWaiver ❑EnvoachmenlPemrn ❑ACossAgraelnaA COMMENTSICONDITIONS: 1L O $ G S joe-5 p-eA- La for WP TYPE PE SC FEE INFO AMT REmrrrED CHECK# RECV D Y DATE WELL PERMIT# INVOICES Permit 2 V5 31 s152x p$ 30 .. Z - 1868 E. Hazelton Avenue I Sto On, ornia 952051 T 209 468-34201 F 209 464-0138 1 www.sicehd.com EHD 2"I0a01-lT Sne Mitlpeeon We'Pema Applraaon