Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> LOP <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE MITIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 UNIT IV <br /> Telephone:(209) 468-3454 Fax: (209) 468-3433 Web: <br /> WWW,si <br /> -qov.ora/ehcV­'-.v- <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO <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 Mj <br /> 6Q <br /> ,!��,I#ance with San <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standard of the San Joaquin County Environmental Health Deparri -ALTH <br /> Site Location ross Street 15 CityVMA141� Zip <br /> Property -LI -11W — APN <br /> Owner Address <br /> Ity 344.. 12 P n <br /> C-57 ContractoeC '-h 5'�C ZiP.34/,/) In. <br /> al��A--I Address K14HI - – <br /> Consultarit'Sub Cntr &At) CitY!–�hj t90(-rf-0 Lic 3'5�7 5;-P.�; Phone <br /> Address City�6 _Lic_Phone <br /> Billable Party OMA Address IL16 11c"V'&-4A.1 6-f, City Wcme 6 zip���0 Phone N!;- 76 2- <br /> GIS Coordinates:X Y <br /> I I--4-4�--14 <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> 0 NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDS <br /> F1 WELL IDs <br /> 0 OTHER 6-s­ <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING El HOLLOW STEM DIA.OF BOREHOLE —El MULTIPLE CASINGS E:1 MULTI-LEVEL WELL CASING DIA <br /> EXTRACTION:Vaport Water E3 HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br /> Sol; VAPOR PROBE C3 MUD ROTARY DEPTH OF GROUT SEAL <br /> ----_____jREMIE TYPE TO BE USED: 0 AUGERS []HOSE 0 PIPE <br /> —E]SOIL BORING 0 PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes [I No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _E3 INJECTION(J.e Air Sparge.ozone)[]HAND AUGER GROUT SPECIFICATIONS <br /> _[-]OTHER: El OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No El Yes:Casing Dia:_Casing Depth:_ Boring Dia:_ <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> OF WELL(S)TO BE DESTROYED fz-1 t-r D DESTIR CTION METHOD:(CHECK Al I THAT APPLY) <br /> WELL IDs: '?-I – !I , >, - r"2-10 40 Li OVER-BORE DIAMETER OF --INCHES TO DEPTH OF FT <br /> GROUT SPECIFICATI-O S ED PRESSURE GROUT TO IDEP77H OF <br /> FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED:Og AUGERS LJ HOSE U PIPE El EXPLOSIVES FROM_TO <br /> OV15f <br /> Zj)/L _FT BELOW SURFACE <br /> COMMENTS [I MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE <br /> &4. - %At IT%4 JALN-'atcZ -AA,,r,!:, <br /> 5WORKING=AYSI,1Cr- mr-wUlmr-u(Al- 1tK 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,�aalll a;pplicable Ca1r,._ rn�Iaws.,�� <br /> Signed Title/Co <br /> mpany Cj5o <br /> Print Name Date—!q <br /> DEPARTMENT USE ONLY F <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS A 4 r -j- <br /> )D'k- a.d, ILE COPY <br /> WORK PLAN DATED 19 11 — <br /> APPLICATION ACCEPTED BY <br /> DATEISSUED 1j AREA <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: <br /> AID# FAC <br /> PE CODES FEEINFO AMT REMITTED CHECK* RECV`D BY DATE SERVICE RO# <br /> act 0 z- $122 x 0c) &4 REQUEST PR# INVOICE <br /> SR# 6 zw3o <br /> RO# <br /> (3500) <br /> *-10 3 3,66-00 PR# <br /> L m�� 67 7--+ct Ic <br /> C-57 V 900) tj I <br /> WC —WAIVER— — C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> EHD29-01 7/28/10 _ENCROACHMENT DOC <br /> WELL�-ER­MJTApp <br />