Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> LOP <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> eg ; ' Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.siaov oro/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION REDEIVED <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O C T 2 5 2012 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departrr�l(VIRONMENTALt•{EALTM <br /> P C s R SERVI�FSS <br /> Site Location_ 16)(i 6 S P,}k.- <br /> Property Cross Street S <br /> , [u...-F �,Fr„�: .t.a City/State T'uc., Zip �IS3-77 AP <br /> Owner ;S tae- - i Address PC 13,x 161/ -3 <br /> City/StateS�:,',�wJ, Zip 9c, /6 Phone `116 7o(,- D•IFt <br /> C-57 Contractor [��,��,. ( _ Address �/-62 0 . � - (_ , <br /> I City/State F ,-, (.I Lic `I .'s r r•) Phone_tj l; <br /> Consultant/Sub Cntr A2 L A 6—c Address `ISL /4 D Lei- F< /2 '- City/State i;.,,.., Lic <br /> Billable Party Address Phone 516 <br /> City/State Zip Phone <br /> GIS Coordinates:X y <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> L�j NEW WELL/BORING(CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ©WELL IDs /} S-.6 <br /> ❑OTHER IDs <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ($HOLLOW STEM DIA.OF BOREHOLE o <br /> _❑EXTRACTION:Vapor/Water __.v— O MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> P ❑HAMMER/DRIVEN CASING THICKNESS L TYPE OF CASING: ❑STEEL IB PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL <br /> —❑SOIL BORING —_S_TREMTYPE TO USED: GAUGERS ❑HOSE ❑PIPE <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:®Yes Cl No(MAXIMUM FREE FALL <br /> DEPTH IS 39 FT) <br /> SIN INJECTION(Ug BC-Ms Ozw.l 0 HAND AUGER GROUT SPECIFICATIONS <br /> _[I OTHER: ❑OTHER: APPROX.BORING DEPTH I16 <br /> Oa BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING NNo E]Yes:Casing Dia: <br /> COMMENTS: 6i L i c5 � :.f! Casing Depth:_ Boring Dia'__ <br /> C,c arc. � - <br /> NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #OF WELL(S)TO BE DESTROYED DESTRUCTION METft CHECKALLTHATAPPLYI <br /> WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> GROUTS ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED.❑AUGERS ❑HOSE ❑PIPE ❑ EXPLOSIVES FROM To FT BELOW SURFACE <br /> COMMENTS <br /> El <br /> CAP AT(_3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> 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 <br /> Regulations,and all applicable California laws. <br /> Signedp� � �s y.��{.r <br /> —r- Title/Company i.�,s 1 /.I/t[A Dt- C <br /> Print Name $I moi, I•C 12_ _f. L <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITEADDRESS as 77� p^ / � .r 'jM-N Lo P ?b� <br /> WORK PLAN DATED U 2_6!2 <br /> APPLICATION ACCE D BY DATE I EA 4 7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> r^.r+wrrw <br /> DESTRUCTION INSPECTION BY DATE rQATE /-ZZ-/3 <br /> COMMENTS/CONDITIONS: LJ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> Sod _ REQUEST PR# INVOICE <br /> $125x S 6ZSJ 1 ,60 le_�G /o 3-A ly CIO(,6020 <br /> 3sb3 37s' 37s �d66o /.� /� zy /Z RO# <br /> PR# <br /> (2900 <br /> C-57 WC <br /> WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 <br /> WELL PERMIT APP <br />