Laserfiche WebLink
j • CooI.APY <br /> Htn. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 1868 Hazelton Avenue, Stockton,CA 95205-6232 SITE MITIGATION <br /> Telephone:(209)468-3147 Fax.(209)468-3433 Web:www.sicloy.org/ehd UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> 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 Bre work described. This app/ration is made in compliance with San <br /> Joaquin County Development Title,Chapter a-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location 7091 E Live Oak Road Cross Street Angler City/State Lodi.CA Zip 95240 APN 061-160.06 <br /> POwr�isi ty Kurt and Sandra Kautz Address 5490 Bear Creek Road CitylState Lodi,CA Zip 95240 Phone (209)368-3113 <br /> "7 Contractor Woodward Drillirq Address PO Box 336 City/State RiO w"a"CA Lic 710079 Phone (707)374-4300 <br /> ConsulranuSub Cnlr Fail Creeek Enor Address PO Bot 7834 Cftyl&ate sere c cOA Us 55605 Phone (831)426-1440 <br /> Billable Parry Bear Creek Winery Address 11900 N Furry Road City/State Lodi,CA Zip 95240 Phone (209)368.3113 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ®NEW WELLfBORING(CPT,GEOPROBE.HYDROPUNCH.HANDJIUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ®WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _®MONITORING IN HOLLOW STEM DA OF BOREHOLE 6IDCh ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA 22 inch <br /> _0 EXTRACTION:Vaponwaur O HAMMER/DRIVEN CASINGTHICKNESS SCh 4O TYPE OF CASING: 0 STEEL 19 PVC ❑ OTHER <br /> _D SOIL VAPOR PROBE E3 MUD ROTARY DEPTH OF GROUT SEAL 9S TREMIE TYPE TO BE USED: Ki AUGERS Q HOSE ❑PIPE <br /> _E3 SOIL BORING (]PUSH POINT(GPI CPT) GROUT SEAL PUMPED:III Yes❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _1`1 INJECTION Ila Nrswma.oIDnq I]HAND AUGER GROUT SPECIFICATIONS Neat Cement <br /> ❑OTHER: ❑OTHER; APPROX BORING DEPTH 120 feet D BOLTED TRAFFIC BOX OR M STOVE PIPE <br /> CONDUCTOR CASING 14 No❑Yes:Casing Etta:-Canine Depth:_ Set Die:_ <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DFSTRUC71ON METHOD:tCHECK ALL THATAPPLYI <br /> __#OF WELL($)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IOs: ❑PRESSURE GROUT To DEPTH OF FTBELOWSURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS HOSE PIPE ❑MUSHROOM CAP AT p3 Fn FT aELOW SURFACE <br /> COMM <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 aptpJt ble Cal ornIs <br /> Signed Tibercompany C',V1 InFVt V(,QZ✓ I,� yyRl. (r N�'}� <br /> Print Name to <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITEADORESS_ �S�I U V <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ISSUEDAFOOklU <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE u <br /> COMMENTStCONOMONS: <br /> ACCOUNTING ONLY: AID It FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> q0-7 SI z SR# Oqvl <br /> RO# <br /> X900 <br /> FR* <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO 29-01 5009112 WELL PERMIT APP <br />