Laserfiche WebLink
'( RECEIVED <br /> PgUth SAN JOAQUIN COUNTY <br /> ter, ARE 0 4 :-; `.i <br /> ENVIRONMENTAL HEALTH DEPARTMENT SSS�TT LOP <br /> 600 East Main Street, Stockton, CA 95202-3029 NVIRONME TI Tf�N <br /> . p Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:wuww.siaov.oralti#F <br /> �C]F oiae�� <br /> J7 <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 /> Ir <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. -t <br /> Site Location 932 S Hwy 99 Cross Street Brady Lane City Ripon Zip 95366 APN 261-02-Vll <br /> PropertyAllen Fetters 3660 Arrowhead Crt Stockton 95219 476-8213 <br /> Owner Address city Zip Phone <br /> C-57 Contractor AGE Address 837 Shaw Road City Stockton G ftoo Phone 467-1006 <br /> Consultant/SubCntr AGE Address 837 Shaw City Stockton Phone 467-1006 <br /> Billable Party AGE Address 837 Shaw Road City Stockton lip 9521!F Phone 467-1-006 <br /> GIS Coordinates:X Yr{.�'I+ <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPRppBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> ®SOIL BORING IDs SOil �7a or FILE CUPV <br /> ❑WELL IDs <br /> ❑OTHER IDs .L <br /> TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE2 inch MULTIPLE,CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION:Vapor]Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVG O OTHER <br /> 3 [J�60IL VAPOR PROBE: ❑MUD ROTARY DEPTH OF GROUT SEAL 'Vel f trREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE El PIPE rr� <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑INo(MAXIMUM FREE FALL DEPTH IS 30 FT) W <br /> —❑INJECTION i.e.AirS are Ozone ❑HAND AUGER GROUT SPECIFICATIONS por'tland <br /> _❑OTHER: 0 OTHER', APPROX.BORING DEPTH f iv6 feet ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE ` <br /> CONDUCTOR CASING I]No❑Yes:Casing Dia: Casing Depth: Boring Dia: �(I <br /> COMMENTS: r i <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 WELLS)TO BE DESTROYED - ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT C5 <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 f <br /> COMMENTS <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance:Iwith San Joaquin County Ordinances, Rules and <br /> Regulations,and all plica_ble Californi li. <br /> Signed Title/Company Geologist / AGE <br /> Print Name Will iamLitt e Date 4/4/2011 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS 13 12LE , <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY119 <br /> DATE ISSUED 1I -S-II AREA 149 �C <br /> GROUT77- <br /> INSPECTION BY r FINAL INSPECTION BY 'y f rnridL DATE4-15,-/r <br /> jI <br /> DESTRUCTION INSPECTION BY DATE i <br /> COMM ENTSIC ON DITIONS: 3 V6 112 1r0 <br /> ACCOUNTING ONLY: AID# FAC# } <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> REQUESTPR# INVOICE <br /> • <br /> So .$ 122. l d2 2 p 3 2 3 9 0 � � � S-1 SRS dG 2 249 . m <br /> 3 QO Od a o0 44 3 <br /> �` � d8•�b PR# <br /> � 2900 <br /> C-57 WC WAIVER C-57 LETTER OF-AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07128110 WELL PERMIT APP <br />