WORK PLANS - Laserfiche WebLink

Home Browse Search

REcawo oq,A!'•t.N. SAN JOAQUIN COUNTY MAY 1 8 2017 r` ENVIRONMENTAL HEALTH DEPARTMENT ENVIROA'ME '�"° '• 1868 Hazelton Avenue, Stockton, CA 95205-6232 Nbgt P ry � P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com ERMIT/SER�CES c ki�H 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 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made rIn�compliance ' /with San Joaquin County Development Title,Chapter 9-111115(.3, and the ASan Joaquin County yWell Standards. Job Address L.l�t�� _L �, IM(vAl jjNj City/Sta1t'e/Zip2 'S/ @(,tLIM , (A 9520�Phone 0` '40-b10 Cross Street _ Jy"UAA,t51ti,JS sk APN 141- J`l1-&0 �ll/� Property Owner* �lt #/1 Phone 2fl 1q q60 ` (2 �i Address -I833 ',�Q-Q/'q'.T yt ( (tnq City/statelZip SOC/A vl I 19-13 C-57Contractor \\ Ii^t License# %)6 Re/`/ Phone S7p_(�G��iIoOU Address Zo 16141 1 0 S, CitylState/Zip /tPyv1, 1� ConsultantlSub-Contractor SArAI, Evivi/mrAim 'Yv ., License# N, 10i 1S1 - R,W Phone SS,30-lit I& oZd�pZ Address333t Cnvh e/m & ( ' r City/State/Zip C 6 Z CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite BoringsNVells Require Access Agreements or Encroachment Permits TYPE OF WELLIBORING NUMBER INSTALLATION TYPE CONSTRUCTION SPE IFICATIONS SDI l 9 r.(S 't,Ap1 d W/ kPai khrw ❑ MONITORING ❑ HOLLOW STEM BORING DEPTH 1A BOLTED TRAFFIC BOX ❑STOVE PIPE ❑ EXTRACTION(VaporM'ater) ❑ HAMMERIDRIVEN DIA.OF BOREHOLE Lt-IpT❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASINGDIA ia SOILVAPORPROBE �❑ MUD ROTARY CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER EKSOILBORING -I0 PUSH POINT(GPICPT) CONDUCTORCASING ❑Yes 10 No Boring Dia: _Casing Dia: Casing Depth: [IINJECTIONtosoarasoe, ❑ HANDAUGER GROUT SEAL DEPTH 31 TREMIE TYPETO BE USED: ❑AUGERS ❑NOSE ❑PIPE ❑ OTHER ❑ OTHER: GROUT SEAL PUMPED? ❑Y 11 No (Note:Maximum Frcefall Depth is 30 FI) WEWSOILBORINGIDs GROUT SPECIFICATIONS_yV(t� (JA,Wvv/F DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) #WELLS TO BE DESTROYED ❑OVER-BORE DIAMETER of_inches to depth of feel WELL IDs El PRESSURE GROUT To depth of feet below surface GROUT SPECIFICATIONS El 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 ,,.�r II //�� / San Joaquin County Ordinance Codes and Standards,and all other applicable California laws. Signed_S(,a [S)/U'Ti�/ I� Title/Company Print Name �() lg�fnr-C� Date DEPARTMENT USE ONLY Application Accepted By: - Dale Issued: tv Grout Inspection By/Dates: ,OR1 'K�6A f�fl _7 (_ Destruction Inspection By/Dates: +� Facility/Site Information FA Name 1 I,LS a ;,i V%ct I Zo he- FA Address 4 I � � w FA# (� 23-Z29 PR# v FA PE ut V 0 WP Reviewed By (.. k Work Plan Date Lr I 0G57 0C-57AMgrinlion for Other to Sign Permit ❑Waders Canp ❑Workers Camp Waiver ❑Ervoxhment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR COMMENTS/CONDITIONS: SR TYPE PE I SC I FEE INFO JAMT REMiTTED1 CHECK# I RECV'D BY I DATE I SERVICE REQUEST# INVOICE# Permit J10� 1 '313 $139 x 3 r yl ) 11i'l I I L—X T. !l4/y -7 1 $ 0 p 1 7 7 r,0 Vjjn 7M03 $2-) Y/87/ x b //4/1 -7 5R-00-71'72.j EHD 29-01 10-26-2015 Site Mitigation Well Permit Application