FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

ac4�ly. • SAN JOAQUIN COUNTY • ORIGINAL �`r ENVIRONMENTAL HEALTH DEPARTMENT LOP w`. , 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.siaov.ortlleh UNIT IV LrFO 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. STVLKIVN �,�.I�,i•Dr'-K1C1+` Site Location 41&11 PA-06C LW ' Cross Street Mlil"II' 14tw1; City/State Gt' Zip '15107 APN UU/QF—tirr�—r- V Property / 4r-rctc«r Owner C" pi; St�G►''�ty Address 34S N• City/State aO- Zip 'tSlr'2Z Phone 2c9-�i7-1S1L�ik C-57 Contractor Va IVIVIl . Lave Address I A 6 1 14671, iNt-PIC- City/State 9`14 r Lic x5364 b Phone 9 _(oy 5r2 Consultant/Sub Cntr SV WIVZi Address lS'S"lI-OS 6A'TDS RL�• City/State wLic Phone kj6-3C-&'6/2_ Billable Party C461*ftW V'fvt i Address I tot l0.U"-064A '�"' City/State �ip Phone 4A •7!jQ -Sc_'I GIS Coordinates:X057,112. to Y -r r, 3128 Z CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —0 EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _O SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION(i.e Air$Dame,0mnO0 HAND AUGER GROUT SPECIFICATIONS _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS 8r BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY) / ,�� #OF WELL(S)TO BE DESTROYED %OVER-BORE DIAMETER OF INCHES TO DEPTH OF^"G-S FT vWELL IDs: MW-it r MN/-ts IYIW"-fit = �1 PRESSURE GROUT TO DEPTH OF ��S' FT BELOW SURFACE GROUT SPECIFICATIONS N4,YIT(hcw`T HI.7CNptc ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE l�S JD:❑AUGERS ❑HO E ❑PIPE MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS "I� YK g.1 10a ¢ � •'` IGlea-E+c�. CY\ ryyten a0W. 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 applicable a plicable California laws. Signed _----/5`��` Title/Company 01-ji,2T-S(>tZiA%AST/ :Z&A-e..neva. FAL . Print Name 6t cw%wrj L�i1 n(� Date �/ DEPARTMENT 1 USE ONLY �y,� SITE MAP IN UNIT IV FILE-SITE ADDRESS "1?07 re /7VeA)uE S7beply WORK PLAN DATED J(40jis 1' 70 13 APPLICATION ACCEPTED BY X. b 1qltu.wt DATE ISSUED 9,-Cf-1IF AREA 16 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE PRO: INVOICE L /1 REQUEST J0 2 $130, 3 72 0-paiw82 SR# 3 .3 503z o ss000 5an PR# 2900 C-57 !✓ WC ✓ WAIVER {1-C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC EHD 29-01 7/24/14 WELL PERMIT APP