FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

. -- — "TCEIVED GINAL SAN JOAQUIN COUNTYAUG 2 3 ENVIRONMENTAL HEALTH DEPARTMENT LOP ur `• 1868 Hazelton Avenue, Stockton, CA 95205-629pIVIR13NMENTAL9F MI1MIGATION • ;•.- a.. :P Telephone:(209)468-3147 Fax:(209)468-3433 Web:www.sis WWAF VICE9UNIT IV �%FO 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 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 450 W, Cj jofdg 5-1, Cross Street City/State � Z APN OwProperty erty Ir G o4iddress 9 r'l'o Izy'af. City/State N O Zip 4 $S''3 Phone C-57 Contractor 11; Address City/State Lie 1f8 S/6S Phone Consultant/Sub Cntr U Address &)O-*t$44 f ACVA,4 City/State SAA�SdSJ?--Lic Phone Y4$ 25;79S-19S� Billable Party VAS Address /lam Gf�e f�Z/1eryturd� City/SEate 55T Zip S'/ Phone 208 2y7�8� GIS Coordinates:X Y C NSTRUCTION WORK TO BE PERFORMED: NEW WELL/BORING(CPT,GEO I�OBE,HYDROPUNC HAND-AUGER,OTHER) ,iE SOIL BORING IDs S�tS"I -tl�r.1 S ( ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _0 MONITORING HOLLOW STEM DEA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA _[]EXTRACTION:-Vapodwater ❑HAMMER/DRIVEN CASING THICKNESS - -TYPE-OF-CASING; 0-STEEL ❑PVC-❑ OTHER —0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE FOIL BORING MUSH POINT(GP/CPT) GROUT SEAL PUMPED/Q Yes [jNo(MAXIMUM FREE FALL DEPTH 15 30 FT) _EI_EIINJECTION(i.e.Air Soakone)0 HAND AUGER GROUT SPECIFICATIONS I _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING[]No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: dna(r to 4d T Kc RFS i 'Tn NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL($)TO BE 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 i TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS i 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,and all applicabjg California laws. Signed L— i Title/Company Print Name r yV8 �Q7_ / gs Date 8- Zo'/z ��qq��,,,�, DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS &X W u Re 14 c?* C_r WORK PLAN DATED 1- I Z�r APPLICATION ACCEPTED BY -r. O DATE ISSUE A77,1-41A t�G GROUT INSPECTION BY FINAL INSPECTION BY w I, D DESTRUCTION INSPECTION BY DATE COMM ENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# l pv $125x / - X28 7� v Z3-r 2 SR# 6 fJr 7,2 (33500 PR# 2900 C-57 WC WAIVER A7 C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT d ENCROACHMENT DOC EHD 29-01 5/09/12 WELL PERMIT APP