FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

0 In• SAN JOAQUIN COUNTY '`•�`•''•c LOP �; ew ENVIRONMENTAL HEALTH DEPARTMENT SITE MITIGATION 600 East Main Street, Stockton, CA 95202-3029 UNIT IV Id... Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.siaov.or0lehd 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, 167-0q 0 ob Site Location IIIb E.li•t5k 51+cet Cross Street Upildirl Sweet city Slnrkktm Zip 45 20'D APN 141-0 0-06 11.9-o30-r3 Properly owner C.fi) 06 SiaCKtbH Address 495 N.EI D.+441e SIVee� city Siackhvt zip ?15;102 Phone ao9.937•441I C-67 Contractor RST Dri IIi!nj Address 22o IN. 1Fa4SI- 5t` city u S Lic Phone S 30•!oG 8. 2N9y Consultant/Sub Cntr e� Address 1g4o WPrnl[I 0.11 Sit.loo City o-qk I otd UIt� Phone Po.'ii doe Billable Party Address 1j Clty 'r Zip ' Phone , GIS Coordinates:X SV " Y 121'It., CONSTRUCTION WORK TO RIF PERFORMED: NEW WELLIBORING(CPT, EOPR HypROPUNCH, ANDAUGER OTHER) E]SOIL BORING IDs E'�e'�- Isu.aah bra-la �I� hhL.Q ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION'P�ICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 15, ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water 0 HAMMERIDRIVEN CASING THICKNESS I`JTYPE OF CASING: 0 STEEL 0 PVC ❑ OTHER ®SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL II REMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE atig SOIL BORING ®PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION da,Gi[.5aa0 HAND AUGER GROUT SPECIFICATIONS - - l10 OTHER:�_ ❑OTHER: APPROX.BORING DEPTH 35' Ie1 f ❑BOLTED TRAFFIC BOX OR C1 STOVE PIPE 1 1, 1 (` CONDUCTOR CASING M No 0 Yes:Casing Dia: Casing Depth: Boring Dia:_ COMMENTS: 1'kj'a 6A&Adi aJs✓ TC�IC ']b11 NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED E]OVER-BORE DIAMETER OF INCHgSTODEPTHOF FT EL WL IDs: RPRESSURE GROUT TO DEPT H OF 3 S FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances,Rules and Regulations,aAd all applicable cciee/1 fornia laws. 7 Signed t.�r�G Q N- Title/Company 5t"4v �'>Po�e4l 5!< �i•I•44 -� CNVI�oT�''i�✓I� 1 � Print Name Lr✓nlq r,60lll Date of ILI II DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS �!I l0 t • �'.1�L3�' t— 15•� WORK PLAN DATED D�91 i, APPLICATION ACCEPTED BY // tr DATE ISSUED IW a AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE ! Z 1 �yI DESTRUCTION INSPECTION BY c DATE COMMENTSICONDITIONS: t`/ ACCOUNTING ONLY: AID# FAG# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# T $,zzX ► l 2 z �. .• L NIL 7 SR#(>/7 a"1 RO# O� U �. f 0 I, r+ 3500 ;251 S(2 1SU 280 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EMD 28-01 07/28/10 WELL PERMIT APP