Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone. (209) 468-3420 Fax: (209) 468-3433 Web:www.sicehd.com <br /> SITE MITIGATION 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. <br /> This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and the San Joaquin County Well Standards. <br /> Job Address L{ City/State/Zip r� <br /> Cross street <br /> C Phone <br /> rxx�on to,54 PIN J„C?c;7_S9 1 Ib <br /> Property owner* , C <br /> Address 01 F., Phone 7 Z7 _ 3Z7to <br /> City/State/Zip - <br /> C-57Contractor �,� p pr:u <br /> License# <br /> Address 20c3(? E, Mq� ck.. — ��a1L17 Phone <br /> City/State/Zip Consultant/Sub-Contractor u.o,n,r \. 1 L <br /> License# <br /> Address '77)7to �� � �P c S., 6 Arlo Phone rT�i�f-zit— IS?7 <br /> City/State/Zip lt_�..�A gzrpo'Z <br /> CONSTRUCTION WORK TO BE PERFORMED:'Note: Offsite Borings/VVells Require Access Agreements or Encroachment Permits <br /> TYPE OF WELL/BORING NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 71,MONITORING ��� HOLLOW STEM BORING DEPTH <br /> EXTRACTION(Vapor/Water) ❑ HAMMER/DRIVEN - Y IL'—='F+_❑BOLTED TRAFFIC BOX r�r STOVE PIPE <br /> ❑ SOIL VAPOR PROBE DIA.OF BOREHOLE ti L <br /> ❑ MUD ROTARY �r^r�" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DU1 <br /> ❑ SOIL BORING CASING THICKNESS 4in xhcl0 •/C TYPE OF CASING: ❑STEEL 14 PVC ❑ OTHER <br /> ❑ PUSH POINT(GPI CPT) CONDUCTOR CASING ❑yes No Boring <br /> ❑ INJECTIONrur9ora-Omni ❑ HAND AUGER NA Casing Dia. r)A Casing Depth: yA <br /> ❑ OTHER GROUT DEPTH _G5 �-. TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE j�PIPE <br /> ❑ OTHER: GROUT SEAL PUMPED? Y <br /> WELL/SOIL BORING IDs �(11 j)_/j n ® es No (Note:A�,imam Freefall Depth is 30 FI) <br /> GROUT SPECIFICATIONS_(re,� Ao,n� (--I{r­)T_ <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> DESTRUCTION METHOD:(CHECK ALL THAT APPLY <br /> #WELLS TO BE DESTROYED �A <br /> WELL IDs ❑OVER-BORE DIANIETER of inches to depth of feet <br /> GROUT SPECIFICATIONS ❑PRESSURE GROUT To depth of feet below surface <br /> TREMIE TYPE TO BE USED ❑AUGERS ❑HOSE ❑PIPE ❑EXPLOSIVES From to feet below surface <br /> COMMENTS: ❑MUSHROOM CAP ❑3(eet below surface or feet below surface if>3 feel <br /> I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br /> San,Joaquin County Ordinance Codes and Standards,and all other applicable California laws. <br /> Signed I Off\ <br /> Title/Company� (,p .� <br /> th \ P� a.c- 1 ,(, l�/"Sr„t1R_c Cnns• E r*TS <br /> Print Name F.-% Date xfGVt 'A,[ . 2 0{'1 <br /> Application Accepted By: '` DEPARTMENT USE ONLY <br /> Z. <br /> Grout Inspection By/Dates: Date Issued: <br /> Destruction Inspection By/Dates: <br /> Facili /Site Information <br /> FA Name r�. LO �`� t FA Address ZA gU( ;j• �vj`kA 20FA# <br /> FA PE WP Reviewed By <br /> Work Plan Date <br /> ❑C-57 ❑C-57 Authorization for Other to Sign Permit ❑Woftes Com 2 Iu f 1-1 3 (1 <br /> P ❑Worker s Comp Waiver Encroachment Permit ❑Access Agreement ❑Lead Agency Approval ❑MFR <br /> COMMENTS/CONDITIONS: <br /> SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REQUEST# INVOICE# <br /> Permit e I $139 x l <br /> 33�`t�1 �f J,z/1� S�.tr0�7�LoP <br /> EHD 29-01 10-26-2015 <br /> Site Mitigation Well Permit Application <br />