Laserfiche WebLink
SAN JOAQUIN COUNTY RECEIVE,: <br /> ENVIRONMENTAL HEALTH DEPARTMENT III � ?�p��9� <br /> `I 600 East Main Street, Stockton, CA 95202-3029 S1TEYNtT1 60N <br /> q P Telephone: (209) 468-3147 Fax: (209)468-3433 Web:vvww.sigov.or!zt UNIT IV <br /> NIALMEALTH <br /> ` <br /> -V/�� �rFOR M <br /> (y{� o'I WELL & BORING PERMIT APPLICATION PERMIT/8ERG10ES <br /> -I�p FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Department. <br /> Site Location 500 East Louise Avgoas Street Harlan Road City Lathrop Zip 95330 APN 198-120-09 <br /> Property R«B Louise 1200 Concord vet Concord, CA 94520 9256748400 <br /> owner Address UI a 200 City Zip Phone <br /> c-57Contractor AGE Address 837 Shaw Road cityStockton,CA Lic 680227 Phone 2094671006 <br /> ConsultanUSub Cntr Address " " City " " Lic n Phone <br /> Billable Party Reynolds/Brown Address 1200 Concord Ave city Concord. CFkip 94520 Phone 9256748400 <br /> GIS Coordinates:X Y Suite 200 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> )MOIL BORING IDs B# to B# (approximately up to 20) <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE2 inch ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> _E]EXTRACTION:Vaporl Water ❑HAMMERIDRIVEN CASING THICKNESS ' TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE [I MUD ROTARY DEPTH OF GROUT SEAL 30 ft TREMIE TYPE TO BE USED: I]AUGERS ❑HOSE X PIPE <br /> _iX SOIL BORING 'R PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(Le.NrSoame.ozone)❑HAND AUGER GROUT SPECIFICATIONS POrtland <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 30 ft ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECKALLTHAT APPLY) <br /> _#OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> COMMENTS <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�a �ppIic,a�bbl,le� Ca�[Iforn' I w . <br /> Signed �l- CsV�_ Title/Company AGE <br /> Print Name William Little Date 7/22/15 <br /> DEPARTMENT USE ONLY <br /> �L// <br /> SITE MAP IN UNIT IV FILE-SIT ADDRESS 14W9C lhle <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY Ory DATE ISSUED S AREA <br /> GROUT INSPECTION BY P FINAL INSPECTION BY (/ O DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM M ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: ( AID# - FAC# r <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVIE RO# INVOICE <br /> REOUECST PR# <br /> 2905 $I $ 390 1195 sR# p67Z785 <br /> RO# <br /> (3500 <br /> PR# <br /> (290o <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 01/13/12 „• I, , / <<••• w , • I r — WELL PERMIT APP <br />