Laserfiche WebLink
°a y~ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> Iy. SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.sigov.ora/ehd UNIT IV <br /> , FOR. <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 the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location LI4L-cLl -)i Cross Street LyGcrw-r` City ZiP251-­L APN 1'77-z"1Q 1-7 <br /> Property <br /> Owner (, .s}, City rl}dcZ-x Zip/SL'Z Phone <br /> i�.t� �f�1�G-�-T1� W(--Address f'AM1'-� <br /> C-57 Contractor 'VJQ60yQA4-0 bWfl�dress 550 RjJ6-eL QUO City PO III`/* Lic op Phone 7,02 may"5/30<3 <br /> Consultant/Sub Cntr Address City Lic Phone <br /> OtAot <br /> Billable PartyN,^AT1{,W�1,-��trwAC Address - fl gf°��t� 2P City p `7°V-DLP Phone 31p'79$�YBX�'� <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> SOIL BORING IDs <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 3 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN CASING THICKNESS N)A TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL Io' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [PIPE <br /> SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:Q Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(I a.Air Soarae.Ozones❑HAND AUGER GROUT SPECIFICATIONS N Eo-r <br /> _❑OTHER (3 OTHERAPPROX BORING DEPTH )01 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING&No❑Yes:Casing Dia: Casing Depth: Boring Dia. <br /> COMMENTS: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> WELL IDs: ❑ PRESSURE GROUT TO DEPTH of FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> COMMENTS <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 applicable California Laws. <br /> Signed Title/Company J"1fwAVr � n}waa� W�Srw�� <br /> Print Name �v c C- (24-E---) Date )Z-z-- T t <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE SITE ADDRESS Z�( �I <br /> WORK PLAN DATED ?mob( <br /> APPLICATION ACCEPTED BY DATE ISSUED Z LI AREA' <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE- <br /> COMM ENTS/CON DITION S: <br /> ATECOMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> �j REQUEST PR# <br /> S125x SR#CC) 3- <br /> a��� RO# <br /> 3500 <br /> 2900)PR <br /> as3��3o <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />