Laserfiche WebLink
I <br /> I <br /> SAN JOAQUIN COUNTY <br /> LOP <br /> " ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ °N <br /> 60D East Main Street,Stockton,CA 95202-3029 RE <br /> Telephone:(249)468-3454 Fax:(209)468-3433 Web:wwwsiaov.o tt�ghd <br /> I WELL & BORING PERMIT APPLICATION DEC 212010 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND RF-MEDIATION <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HCALTH <br /> PE <br /> Application is hereby made to San Joaquin County far a perp t to construct and/or install the work descn'bed. This application IS M. (h t <br /> Joaquin County Developrneru Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Hearth Department <br /> j Site Location �Ll{S C�teRs�t.pi'. Cross Street City kfpg__Z'rP__%3.AjS_. APN•Lq t 00/,_ <br /> All <br /> Owner :A&61 GAlAiarm" jwb' a Address S W, w�wg�SE Ctiy *W4.too zip qS 3 PhoneCom)wrG 1C3z,T <br /> C-S7 Contractor � Ha Address {S# {G�.� t�. City_Aa aja Lic� 15 is Phan 6i�313'03LIE <br /> Consutta VSub CnU "fQG —7 Address 1 Not;x A city 4M.j L.ic Phone tri2f)6:3r-3"3 <br /> Billable Party i Cd fwmi, igr d Address <c wra wi —/xr�— City Zip Phone <br /> +' i <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> Il NEW WELL 50PtNG(CPT,GEOPROSE.HYDROPUNCH.HAND-AUGER,OTHER) <br /> ©SOIL BORING IDs <br /> i 0 WELL IDs <br /> { I]OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _Q moNrrORiNG ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> If _Q EXTRACTION:Vapod Water Q HAMMER/DRIVEN CASING THICKNESS TYPE OF CASWG' ❑STEEL ❑PNC ❑ OTHER <br /> _0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> I _O SOIL BORING ❑PUSH POINT(GP/On GROUT SEAL PUMPED:17 Yea 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> { _❑INJECTION Ct.Nr Soyot,Oz wr1❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC,BOX OR ❑STONE PIPE <br /> CONDUCTOR CASING❑No 0 Yes:Casing Dia: Casing Depth: Boring DIw <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> 2UMUCTON WORK TO BE PERFO D: 00 1@MOD:(CHECK ALL THAT APPt.Y) <br /> #OFwwTO8E D R-BORE DIAMETER OF j WHES TD DEPTH OF 61' __.-.FT <br /> WELL IDs PRESSURE GROUT TD DEPTH OF Fr BELOW SURFACE <br /> GROUT SPECIFICA I]EXPLOSIVES FROM To FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED HOSE El F4PE ❑MUSHROOM CAP AT L?3 FI) FT SELOW SURFACE <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS <br /> I txrelry cartlty that t have pfepard plication and that the work will be done/»aeewrdamce with San Joaquin County Ortlinaneas,Rotas and <br /> RegufaHO awr+. <br /> Signed TWeJCompany �A �«��' <br /> P Name Date l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT tV FILE-SITE ADDRESS <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUED Z Z i AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSACON Dt7TO NS, <br /> { <br /> ACCOUNTING ONLY: AID# FAC IF <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> V-0 Z- $122x SR# <br /> 3So 3 6d� Ra# bsZ_ <br /> PR# <br /> I 2900 <br /> C-57 VVC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29 1 07l2at10 WELL PERMITAPP <br />