FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ,.A LOP N ENVIRONMENTAL HEALTH DEPARTNIL T R 'I,ED 600 East Main Street, Stockton , CA 95202-3029 1 �/ c� ;a• ( Telephone: 209) I1 468-3454 Fax: 209 468-3433 Web: www.siaov.orcalehd d�IFsR� APR 2 6 2011 WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REME&jk%MENTALHEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work desc(bed. This application is made in compliance with San Joaquin County Development Title,, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 630N: G �. I N7 rnj'cg rCross Street paK city �4<� y'4n Zip 95 � Z APN I3V65I0 Property spM1 ) 0a %vin Cawnty Address 22z ta97Wt {2trl�lVt �itySS j-ackEP;n «Zip95UT Phone209) g46` cI62 Owner c n 7 d C-57 Contractor 1 - ISL , Or/lkina� Address 31(�50 JatiA10P Itict city H d.C3 Y'� I � t �Lic 6�3965 Phone (707� 769' 18'01 ConsultantlSub Cntrl1G� A ^ Address ) uf� F�tin6 )n/e57C/`, J`rolCity STa<<e�'f'Art 5� tic 73407K6 PhaneA/ 09}) T3 �O6/9 Billable Party Con aOr_CaPTA T4x� Address I�� fu.+�(ti l'✓LSTC/iSde�TLity Sr& c4Tdn Zip 732a ZG Phan4,9L23W',j5j8 GIS Coordinates: X 6335013 Y Z 17 � 161 CONSTRUCTION WORK TO BE PERFORMED: NEW WELLIBORING (CPT, GEOPROBE, HYDROP};NCc,,H, HAN0.AUG 1p'p3, OTHER) F1 SOIL BORING IDs Sn T;S ❑ WELL IDs ❑ OTHER IDs TYPE & # OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE .Z In9h❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _❑ EXTRACTION: Vapor/ Water ❑ HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER _❑ SOIL VAPOR PROBE ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE F3 W SOIL BORING MPUSH POINT (GP/ CPT) GROUT SEAL PUMPED: ❑ Yes ® No (MAXIMUM FREE FALL DEPTH IS 30 FT) INJECTION fe Air SoaMe Ozone) ❑ HAND.AUGER GROUT SPECIFICATIONS Y} tot T- Cer✓6enT- ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH 3Q " Ib ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE / tqq qq / CONDU TOR.CQSI ❑ No Yeses: C,a�y�g DIa: Casing Depth: Boring Dia: COMMENTS: L'112fl1 { Ts ` VI I,I`.� T lr�t1/� I X� 1� �g•�T-II•`I- f'' /9T_ P I6� YL� �� 17 / 5 .9 �7<- NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOID: (CHECKALL THATAPPLY) # OFWELL(S) TOBE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT (>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, ag`d al��cabl, a Caljfo�Jpyja laws. / Signed �/�� !/r C6+'Jf� Title/Company 41=7S�4�cC_ �J4eh/� r� i y_1_Can. d0 f ' Print Name Or ) ( lg C agh Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE - SITE ADDRESS WORKPLANDATED qJ1311f ` V APPLICATION ACCEPTED BY (�I `wnnil/ f9 r DATE-ISSUED-- Z''d' AREA GROUT INSPECTION BY I /I _ FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY /rT DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID # FAC # VCODESFEEINFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST PR # 122x Z-1r ev 2.. 1& , vSR#36< nr� 12,bL( RO # 3500 PR # 2900) C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT jr ENCROACHMENT DOC WELL PERMIT APP EHD 29-.01 07128/10