FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

NA1N JUAQU11N CUU.N 11 - WLLL FEF_Nl T-APPL.pdf http://www.sjgo erjsfWEL1,P,FfflvITT APPL.p - -oo.,a``•'•IM' c SAN JOAQUIN COUNTY }� ? ENVIRONMENTAL HEALTH DEPARTMENT -' LOP y' '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION • rq. _'- ;P Telephone: (209) 468-3454 Fax:(209) 468-3433 Web:w_ ww.sigov.orglehels• Z= .,•UNIT IV �IFoa�' tla' k `I/ WELL & BORING PERMIT APPLICATION a�, FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIQ`l�ft 15 ZOj j NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application i!sg�r��d, n j��orr plif cerwjM-San Joaquin County Development Title,Chapter 9-1115.3,and the Standards of theSanJoaquin County Environmental Health Dep�►fifie t 9- 1LTH Site Location �Y 9/ /F•�ffr([f Cross Street to S�i'tC I 13�fcr< cfS3 vEr�iv�I Property T Y Zip_ APN gQ 6L) _ Owner ✓ erry �DO/'L Address PV 134X &7 City /3`'-^/f- Zip 9S3a -(Phone(Z°9 ?'3-�_ 7-75D C-57 Contractor V*WDr;/l'n5 Address 3�oCs t'%CkCece(- D/ City 540ckfte% Lic -720`/0YPhoneCzo9)Y7S-frgeO ronsultarTUSub,Cn"P-cX-f-lu,rv�"Address—/12gc(-PyrI Billable Party Address City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION Qe.AJrSparoe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS _❑OTHER ❑OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casirg Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS 1'OeTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) 7 #OF WELL(S)TO BE DESTROYED ':;'� ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELLIDs: 5et -r44,/-c_ I Nw-I`/.1f7w-//I,I�IWT/iZ�QSSf ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS 5ct T-bic ❑ EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE XPIPE ❑MUSHROOM CAP AT L3 FT) F7 BELOW URFAc,E COMMENTS Ste t ek-,O/ss•� o4{et/ Tu/j /Ce 2aI't -C'ar dts+yve/--' A- C.AA-rd e,—SeE Z? /o r� is�Z�dOJfr�� 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that I havepre ed this application Amd that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations and alfa lira aliforni S. Signed TitlerCompany 7Co% 4i t�► �i0e� Print Name P-11C11A EL U AtJ Date 3 ce 13 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S l-1 9 577-kC WORK PLAN DATED I r/G-`( 1 (, , ZO/ APPLICATI ON ACCEPTED BY _�. '�U9dct� DATE IS jD 2 7-'3 AREA l GROUT INSPECTION BY FINAL INS//PECTION BY / -AGATE DESTRUCTION INSPECTION BY i�C��Sl.fit L- DATE G//i /3 COMM ENTSICONDITIONS: --T- ACCOUNTING ONLY: AID FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# OZ- $125x '7 O�5 (yCoiz)vi�f 3-/1/3 sR# 4G 2 3 75 3_?5- 375 RO# (3500) PR# (2900) C-57 WC WAIVER A,/VT_ E97 LETTER OFAUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC of 2 3/6/2013 9:36 AM