FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

I t+..v-._...:`vP..�....wq�x-aa., ..._..�.�....yra..... :.h...•..r...� �-,.�-...-�+.sw.,,.r•w.+.,......�..�_.........,-..�...... .�...- ...i,,,•-�M�.w.......-....—_+we........w...-». ,...�+�-.c- w.•,. ...�......��.. - - .....v.%nii iVjHLSEi"rt:..ri::��'.'.3:�'1'.:•il.i:,:.:i'Siisi.wlW..1•i.Yi.IK.. ..«-_..;�✓;w.W::,ik,�r.ant.:.r,:5'.ru6lAur.tl.o,.::-rti:u:.:r:tx„'�:..,::�:.�:::�.�:R+1:.^.'F«.._.-:.e:.,;,o,:tJL•.x:-o:F a:.iW�x/.wr�w:,::ulcera:n:.:.v.�.r•. _., SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE MmGATION 600 East Main Street;Stockton,CA 95202-3029 UNIT IV' a. Telephone:(209) 468-3454 Fax.(209)468.3433 Web:www.siuov.orolehd WELL & BORING PERMIT APPLICATION ^ FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION SON-REFUNDABLE PERMITP� IRES YEARFROM DATE ISSUED Application Is hereby made to San Joaquin County for a permit to constructand/or install the work described,�This application is made In compllanca with San Joaquin County Development Title,Chapter 9-1115.3,and the Standards orthe San Jaaquln County Environmental Health Department, Site Location I1 IXAlPC Rd Cross Street�Q�Itjikn pY(M•'�1._� City Y_Zip�Q� APN 11 ZO3C p Property_ jAyal t-9 Address jig A twK-er1l,_.)�!t�Z city emied.� zip�Phone C•S7 contractor tr l' AddressClSQ pe 4�l City nrtin ��Lic445tRa 5 Phone011-S•31,; SSS, Cansuitar►USub Cntr Address t e ' Dr�23D City, 11orf�Ol L� Phona?D"I.0323 Billable Party ._ 1 Address. City Zip Phone GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFQRMED: ' ❑NEW WELLIBORING(CPT.GEOPRRBE,HYPROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE A.9 OF WELLIBORING INUM4MON TYPE CONSTRUCTION SPECIFICATIONS __._I]MOME?bRING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMERIORIVEN CASING THICKNESS, TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE' ❑MUD ROTARY DEPT14 OF GROUTSEAL . TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE ❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUfMPED:❑Yes 13 No(MAXIMUM FREE FAIiL DEPTH 15 30 FT) LJ3 INJECTION"Alf Sparge.Ozones❑HAND AUGER GROUT SPECIFICATIONS `❑OTHER: ° O OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC.BOX ORL❑STOVE PIPE CONDUCTOR CASING[3 No 17 Yes:Casing Dla:. Casing Depth: BodnO Dia: , COMMENTS: NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS D CTION WORK TO RE PERSORMED: ]2g§IRUCTION METHOD:(CHECK ALL THAT APPLYI 4 #OF ELL S)TOBE DESTROYED 4 OVER-BORE DIAMETER OF�INCHES TO DEPTH of 240 Fr ' WELL IDs: PRESSURE GROUT TO DEPTH OF FT aE:LOW SURFACE GROUT SPECIFICATIONS p EXPLOSIVES FROM To FT BELOW SURFACE 7REMIE TYPE B U E A G R5 [I HOSE-JaPIPE Q MUSH 00 CAPAT3 FT) r FUDW SURFACE COMMENTS >• 5 WORKING DAYS NOICS REQUI ED(AFTER PERMIT",SSUANCE)FOR IN- SP=CTION APPOINTMENTS I hereby certify that 1 have prepared this application and that the work wlll'be done In accordance with Sen Joaquin County Ordinances,Rules and Rogulatlon d a ppll California laws. ��• SI no l �oCGw. ®�rS�eC aquelCompany Print Nome R-- Date. ////0// DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS_- 7 'FL (NdjIV4' L.1 V%A yzo cl", WORK PLAN DATED 2 (o APPLICATION ACCEPTED BY " DATE ISSUED 1 f 12 ii AREA GROUT INSPECTION BY FINAL INSPECTION BY (A\,tAnA ��dDATE DESTRUCTION INSPECTION BY DATE. COMMENTS/CONDITIONS: S ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECNr.D BY DA(' SERVICE. RID# INVOICE: REQUEST PRO 3saZ. 122X 2 #2.`i`d• - 2o3�s''# 11 �Z,((USRN c,(`11 KO �y�3 . asoo 5o 36b Zp34s6 1t /vj10 PR# xstia C-57 WC .WAIVER C-S7 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 28-01 07128/10 - - WELL PERMIT APP ILE . My 1