WORK PLANS - Laserfiche WebLink

Home Browse Search

PAYMENT RECEIVED ,. SEP 2 2 2014 SAN JOAQUIN COUNTY LOP sANJOAau'NcourFCNVIRONMENTALHEALTH EPARTMENT SITE MITIGATION H EFaN PDcpgRTTMENT 600 East Main Street, Stockton, CA 95202-3029 UNIT IV •ar Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.s'c ov.or ;Foa� C�10MID WELL & BORING PERMIT APPLICATION �gN21 [O10 FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDI NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRpU�NIVILN I HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application PEgpy+l`tT/�r pRv t U[JSan Joaquin County Development Title,Chapter 9-1115.3,and the Standards of a San Joaquin Co my vnonm II yealth Department. Y`c1�rT v'V CJ II..11 II,,11 /nI {CMQ%IC \Ik* 1+e(NWn Ft[IPn5 VNriN GG r Site Location) W' Cross Street W'!� D City S'�kk4 a Zip APN 6G 1 ' 1C0 I Property �/�A,,,�I�( Owner ° � Address City 4 1 + Zip_�A Q „Phone tfl- C-57Contractol'` r 11A Address City LIC'7/ 1� Phone) y6�co ConsultentISub Cntr k�'PI RtYl711t1 Address – ' City S�o 4 i Lic_ k)pt �hon� Billable PartyCDA- ofit k Qios Address 11 a 1 ! City Lodi Zip 2. one GIS Coordinates: Y-Li� 1803L CONSTRUCTION fl�h �{I3aI 7o12 CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA- _E]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS It TYPE OF CASING: ❑STEEL.!(PVC ❑ OTHER —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE —❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTI . .Air gr a. zone ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: APPROX.BORING DEPTH ILA 6V ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS ``11 STRUCTION WORK TO BE PERFORMED: - ESTRUCTION METHOD: CHECK ALL THAT APPLY) ( / -6—#OF EL (5)T BE DEBT(tOVED I1 VER-BOREDIAMETER OF INCHES TO DEPTH OF WELL IDs: Y �3 C ❑PRESSURE GROUT TO DEPTH F FT BELOW SURFACE GROUT SPECIFI ONS – ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYP T B USED: ARS WVO&❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certi that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation ,a A all plica a California laws. Signed Title/CompanyA`(t(- Print Name Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS W El &f+T MI L-E K019-P Si�Knnl WORK PLAN DATED �1 APPLICATION ACCEPTED BY DATE ISSUED 9 V AREA 4 GROUT INSPECTION BY FINAL INSPECTI N BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: CAS ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE REE RVICE ERO PRO# INVOICE QUST 2gbz $122X 4732— Sig a7sz SR# OD(olla 500 i o0 535 314 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP