Laserfiche WebLink
"4U1 ' SAN JOAQUIN COUNTY <br /> °i ENhONMENTAL HEALTH DEPART*LONT ~- ` r D <br /> �tBY. 600 East Main Street, Stockton, CA 95202-3029 SIT5AI,TIATION <br /> 4t F Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: wwws' ov.or /eh ��1T-'IV <br /> WELL & BORING PERMIT APPLICATION EN4 tCNMENT4 HEALTH <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM EDIATIOWR/v'T r/c"'thCES <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 /> 14749 Thomton Road Thornton Rd.&H 12 <br /> Site Location Cross Street City Lodi Zip 95242 APN 055-150-26 <br /> Property Tony Khatidne 14749 Thornton Rd. <br /> Owner Address City Lodi Zi 95242 phone 209-369-9100 <br /> C-57 Contractor All Well Abandon 9245 Beatty Drive, Sacramento p 948359 916-363-9355 <br /> Address City Lic Phone <br /> Consultant/Sub Cntr Advanced Geo Env. Address 837 Shaw Rd. Stockton 680227 209-467-1006 <br /> City Lic Phone <br /> Billable Pa Tony KhaBdne 14749 Thomton Rd. City Lodi Zip 95242 phone <br /> Party Address 209-368-8100 <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(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 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> _0 EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER <br /> _0 SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> _0 SOIL BORING 0 PUSH POINT(GPI CPT) GROUT SEAL PUMPED:0 Yes 0 No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _0 INJECTION(is Air Scarce.Ozone)0 HAND AUGER GROUT SPECIFICATIONS <br /> _0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING 0 No 0 Yes:Casing Dia: Casing Depth: Boring Dia: <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 32_#OF WELL(S)TO BE DESTROYED ®OVER-BORE DIAMETER OF 825 INCHES TO DEPTH OF 46 FT <br /> WELL IDs:MW-1 TO MW-6,MW-16,MW-1 7,VW-1 TO VW-6,AW-1 TO AW-18 ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS PORTLAND TYPE II ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: ®AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT >3 <br /> COMMENTS SEE WORK PLAN DATED 13 MAY 2013 FT BELOW SURFACE <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 a-M�-aJl,f applicable CCalif_o1rnia laws. <br /> �/181�Iw 6 �A AIII� PROJECT MANAGER/ADV.GEO ENV. <br /> Signed � Title/Company <br /> Print Name TIMOTH ELLAR Date 06-03-2013 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS l"oZr <br /> WORK PLAN DATED A% f t r <br /> APPLICATION ACCEPTED BY DAT S EA 997 � <br /> GROUT INSPECTION BY FINAL INSPECTION BY ti�� nATE Z /-? <br /> 3 <br /> DESTRUCTION INSPECTION BY 4u el DATE(048'13 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE I RO# INVOICE <br /> .E // REQUEST PR# <br /> 3SV/x/ <br /> $122x3Z 37 U -7� Z c... ( SR#LVG7? <br /> Jd3 (35 0 <br /> 300 5So <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0728/10 WELL PERMIT APP <br />