FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

M0 SAN JOAQUIN COUNTY oc.... ENVIRONMENTAL HEALTH DEPARTMENT OCT rrnlgd, 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATi:JN 1"efephone:(209) 468.3147 Fax:(209)468-3433 Web:wwwwww-BicWAI 41NhT-Fu+ __ IT/SERVICES WELL & BORING PERMIT APPLICATION ILIVELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application c:I - .io u)San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San Joaquin(Jnuniy hent title,Chapter 9-1115.3.and the Standards of the San Joaquin County Environmental Health '! nt. ./ Site Location ;r/. e f rA4 Cross Street U!'n¢/ City/State 1..0 9 Zip APN Oil 0-_Q`/ Property �/ Ownee j -jl + ��"DI-/ Address P.�•'bU�t 7_y9 City/State 0.zlp 'N / Phoneme963-. Y C-57 Contin';n c' wr a— r�_ Address SSO I�•,V!Z`2 IZd City/State��Lic 0 �- Phone �OtZ-37�y -Y3oo ConsultantRz=� .ill d �4, Address3d�5t 5'1.!iJ City/State52pP r,g�Lie K 4 Phone Y/S-ZY3-1/5_0' Billable Paris ,q�.y Jam,.. Address S0.r.._ City/State 'art MCS zip 9 YIO Phone Set Ac C _ GIS Coorriinas:�. --:_a_� Y CONSTRUC-1-lt-A, v nJRK TO BE PERFORMED: -- I�NEW_WF_LI.0, : IGirt(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) SOIL I:; IDS f�(sl--t2R x7WEi 9 C ( 7-ZU CW-7l ( C)-7L — TYPE&#UI_N!I:(, ,;��It;ING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ±0 MONITOR: a HOLLOW STEM DIA.OF BOREHOLE IJ MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _EI F_XTRACTI Water ❑HAMMERMF IVEN CASING THICKNESS �G� Y D TYPE OF CASING: 0 STEEL 131 PVC [I OTHER _D SOIL.VAP(_. , 0MUD ROTARY ' DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: MAUGERS ❑HOSE 11 PIPE I I'll SOU now. ❑PUSH POINT(GP1 CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECI10I, _::,. nrr,.,gy(jHAND AUGER GROUT SPECIFICATIONS Le-ol CP y/le,Y1't _❑01 HER.-- _ .-„ ❑OTHER: APPROX.BORING DEPTH_ 70 ❑BOLTED TRAFFIC BOX OR M STOVE PIPE COMMEN'T'SCONDUCTOR CASING a No❑Yes:Casing Dia: Casing Depth:_ Boring Dia:_ ._ NOTI:.:. . ..�_,.=SITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTIOM Aft.;PttC TO BE PERFORMED: DESTRUCTION METHOD:r .uRCK A THA'APP Yl #OFWELLI`�) I "F DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs-_ -_ ID PRESSURE F PRESSURE GROUTTODii T BELOW SURFACE GROUT SPECIR:I •-c' ❑EXPLOSIVES FROM TO FT BELOW SURFACE CO M E TYPE It): ISISD:❑AUGERS HOSE PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 V VQ',;t,Iy';G DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify ;ip '-.ma prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations,an,l.111 :,pficabl,Ca11for Ia ' / / Signed �`�- ,-j` '/C / Title/Company G7 t'd/a rS iL Print ��' � -�J� WJ e�..rip Data /0—/7—/, rr±±�� DEPARTMENT USE ONLY SITE MAP IN UNH: :' I--SITE ADDRESS IR A 7 AlI $ RALyK WORK PLAN DA APPLICATIOI,I A( rJ BY DATE ISSUED 10'21f34'3 AREA GROU-r INSFEC�.s:.. _- FINAL INSPECTION BY DATE DESTRUCI IUP!!I i ON BY DATE COMME.NTSP/ (u. .. — rACCOUNTII'LL-i AID# FAC# :. AMT REMITTED CHECK# RECVD BY DATE SERVICE RO# INVOICE-- -- - REQUEST PR# ScramSR#3 JS /cno /37 3 RO# 3500 J 2� iso G835 / C_.5v WAIVER vLh_ C-57 LETTER OFAUTHORRATI_ON TQ_S1Gb PERMIZ. _y. _- ENCROACHMENT-0OC}�i - n-Ir->I WELL PERMIT 2M-t