FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY --) r.• ENVIRONMENTAL HEALTH DEPARTMENT (L; 600 East Main Street, Stockton, CA 95202-3029 SITE ION Te%phone:1209) 468-3454 Fax: (209) 468-3433 Web:www.siaov.orcl UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. Site Location 14749 N. Thornton Rd. Cross Street Thornton Rd./Kettleman Ln Lodi 95245 Property Tony Khatirine Cit y ZIP- APN ®S�$02S 37s1/i Owner Address 14749 N.Thornton Rd. City Lodi Zip 95245 phone 209-368-8100 C-57 Contractor BC2 Env. Address 1150 W.Trenton Ave., Cit, Orange Lic 969758 714-744-2990 Phone Consultant/Sub Cntr 'E• Address 8 haw City Stockton Lic 680227209-467-1006 Billable Party Address A.G.E. 837 Shaw Rd. Phone City Stockton Zip 95215 Phone 209-067-1006 GIS Coordinates:X0�./I S(rc� Y _��.�,5� CONSTRUCTION WORK TO BE PERFORMED• ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) E3 SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE — ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _ _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER ' 0 SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE 0 PIPE _0 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) —0 INJECTION(1,.A,,Soarce Ozones❑HAND AUGER GROUT SPECIFICATIONS —[I OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR LISTOVE PIPE COMMENTS: CONDUCTOR CASING ElNo❑Yes:Casing Dia: Casing Depth:_ Boring Dia: NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECKALLTHATAPPLv J #OF WEL'L((S.)TO BE DESTROYED ®OVER-BORE DIAMETER of INCHES TO DEPTH OF 150, FT WELL IDs: MW-7,-8,-9,-10,-11, -12, -13, -14, -15 El PRESSURE GROUT To DEPTH of GROUT SPECIFICATIONS FT BELOW SURFACE I TREMIE TYPE TO BE USED: AUGERS n HOSE PIPE ❑ EXPLOSIVES FROM To FT BELOW SURFACE COMMENTS SEE WORK FLAN DATED 09 MA 014 ❑MUSHROOM CAP AT L3 FT) FT BELOW SURFACE 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and all applicable Caf" rn'�laws. Signed _ u� �L Tltle/Company PROJECT MANAGER/A.G.E. Print Name TIMOTHY J. nELLAR Date 03/20/2015 �,I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS /7N? 1_1y! ZVeX PON ,1��jy��l (,p p/ WORK PLAN DATED A40 /$3,[zjg APPLICATION ACCEPTED BY .I,Yd*; l DATE ISSUED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE- COMMENTS/CONDITIONS: ATECOMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# IREC%rD BY DATE SERVICE RO# INVOICE REQUEST PR#s rr� � 0 3-23• , SR# RO# 3500 PR# 2900 C-57_� WC WAIVER� C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT l� ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP