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COMPLIANCE INFO
Environmental Health - Public
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EHD Program Facility Records by Street Name
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SACRAMENTO
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302-400
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2900 - Site Mitigation Program
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PR0536660
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COMPLIANCE INFO
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Entry Properties
Last modified
5/20/2020 8:36:14 AM
Creation date
5/20/2020 8:33:18 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0536660
PE
2950
FACILITY_ID
FA0021052
FACILITY_NAME
VACANT LAND
STREET_NUMBER
302-400
Direction
N
STREET_NAME
SACRAMENTO
STREET_TYPE
ST
City
LODI
Zip
95240
APN
04121014
CURRENT_STATUS
01
SITE_LOCATION
302-400 N SACRAMENTO ST
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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r�o <br /> SAN JOAQUIN COUNTY <br /> �� ENVIRONMENTAL HEALTH DEPARRKEj / LOP <br /> :� ��t✓ V <br /> y' a { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> C{qC�o.R.•�P <br /> . Telephone:(209) 468-3454 Fax: (209) 468-3433 Web:Wwy#irw ulg�t>j) UNIT IV <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGEWtAbNX"�XLEAgg& <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT@FOU€AERVICES <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 /> Site Location q��W 41 SCCCOLMe-o',(0 Cross Street Lo,kefs-oa City Lod Zip APN U� I66 0 f 75 <br /> Pro pertyr�-�,� �1 <br /> Own er f� W�c Address,( 1�t City �Z-4 / Zip ?60(,Z-Phone Z C3 68 <br /> C-57 Contractor e: A Address D rw,n � City ! c"04 -.i'V Z-Lic 6 ria hone 83 V�-81 7f <br /> Consultant/Sub ntr f�rc.. C-HCl Address p z�jc-5c�'0L 5T City A• 'A-P-- Lic C� Phone 7 �"7-I C <br /> Billable Party CAO V�TCQ Address �8 Cc XC50 t 5i CityN�3_Zip C11- Phone_ CJ80{y <br /> GIS Coordinates:X Y <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WE6 /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> [-]SOIL BORING IDs_ S hCU <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z / ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> SOIL BORING jkPUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> COMMENTS: <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 WELL(S)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(>3 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,and all applicable California laws. /� `` <br /> Signed Title/Company AC7�o.A-V Q l n c <br /> Print Name L V t C"e, ?,IT T— Date <br /> u D PARTMENT USE ONLY a <br /> SITE MAP IN UNIT IV FIL ITE ADDRESS L �U N. �m�2LbS-t S" , 2Q' <br /> WORK PLAN DATED � ( ' Z5 Zo l I <br /> APPLICATION ACCEPTED BY DATE ISSUED 1/ AREA_ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 019-OC- $122x 12 7 �U 7 SR# 0643, 474 <br /> a 7-73r' 371 2 I N RO# <br /> ~ 3500 <br /> lfl PR# <br /> lot ,5��" 2g # <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 07/28/10 WELL PERMIT APP <br />
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