Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> 1•�1'p <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> "�'•� ` <br /> 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> Telephone: (209)468-0343 Fax:(209)4683433 Web:www.sicehd.com UNIT IV <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 /> Joaquin County Development Title,Chapter&1115.3,and the Standards of the San Joaquin County�EnvizlPI5 ronmental Health Department. <br /> 3Q91 N•ix4ry b4VI Cross street C40VEX 1?97A §aY� ' 314 <br /> She Location city/ ti _ <br /> '--r-- t — ltY • <br /> APN 121611 <br /> — <br /> -419170.6-0845 <br /> 81Propertty <br /> nflDpTA4 # � Address f0•�Qk j7GOrveG <br /> 0-57 Contractor � Addressa�S� as Phoneq'Is'6I1-5791 <br /> l7t �' A is 51�Phone <br /> Consultant/Sub Cntr Address1lS� OQ��4N=Cy/,�,D Cily Sa`tPhone 94 ' q <br /> r <br /> Billable PartySAddress AID bek $7 <br /> Cily/StafA Zlp WJM�—Phone 4Ir-6(7-6'1 / <br /> GIs Coordinates:X37'4S Sj o Y 121' -A&,, 11.oj-w <br /> CONSTRUCTION WORK TO BE PERFORMED• <br /> ❑NEW WELUBORING(CPT,GEOINSe HYg eyy�1Ob Fy�NO-A��B.OTHER) <br /> SOIL BORING IDs_ U' -{-r'fR 17b►'I kS -J <br /> WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELUBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 Q MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> _O EXTRACTION:Vapor/water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL 0 PVC 0 OTHER <br /> _D SOIL VAPOR PROBE 0 MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br /> I3-ICSOIL BORING PUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes Ix No(MAXIMUM FREE FALL_?EPTH IS 30 FT) <br /> _O INJECTION a.e Ar surae.Oz,-e)0 HAND AUGER GROUT SPECIFICATIONS A!CG f1% GP.14RjV <br /> _O OTHER: ❑OTHER: APPROX.BORING DEPTH IS 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS-1 ` EwrQalpQ 80¢1N,6S CONDUCTOR CASING❑No0 es: asing Di Caein9 eprh: Boring Dia:__ <br /> r feMP GW eLLEG7/ays� �4� 5D, <br /> NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO SE PERFORMED: DESTRUCTION METHOD:ICHE KALL THAT APPLY) <br /> #OF WELL(5)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <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 L3 FT) FT BELOW SURFACE <br /> COMMENTS <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,andle C if 3mia I <br /> f'a Ilc I <br /> Signed Title/Company 5CA)IDR t�W,MANA&El's--?A2�!'A/Ele.. E5Z <br /> Print Name 112ZW K 14, MDR R(LL Date 45- 4- ZD1S <br /> DEPA TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS D I , V 114 <br /> WORK PLAN DATED <br /> APPLICATION ACCEPTED BY DATE ED <br /> GROUT INSPECTION BY FINAL INSPECT) N B <br /> DESTRUCTION INSPECTION Y DATE 3 <br /> "do�mrq 0a2 <br /> COMMENTSICONDITIONS: IYO <br /> ACCOUNTING ONLY: AID# FAC# JOAQUIN C <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVIC U L TY <br /> Zn'' / REQUEST PR ,r IUJ 513ox D (/� �j SIS�IS SR# Z <br /> RO# <br /> 3500 <br /> PR# <br /> Y900 011'50 <br /> C-5 WC WAIVER <br /> EHD 29-01 7f24/14 WALETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> oa�9o�� <br /> WELL PERMIT APP <br /> �• <br />