FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

PRO!•. 1, SAN JOAQUIN COUNTY —"r ENVIRONMENTAL HEALTH DEPARTMENT LOP 600 East Main Street, Stockton,CA 95202-3029 SITE MITIGATION d• Telephone:(209)468-3147 Fax:(209)468-3433 Web:wwwsigov.orgleh 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 Joaquin Colunty Development Title.made to San CC-Lhapter 8-11116ror a 3.and thelkto consinact 1Sta dards of the and/or San Joaquin County EnNronmental. This H ahh Department.ionts made In wiance with San Site Location �S6is S.7' 7T- Cross sheet�'r5l- L. S')': City tA441/ zlpsS-! O APN 1416 -.X50-5- . ovine �ITb Address n7Ae -DA,4e �x,Dt'- 1� City,_GLI'd/�_zIp9S 3?1mv Phc �- � p C-67 Contractor ,41 We [� e&An Address 4,�4 9 r �I if City CA-A kJ Lic 3y�• Phone �G " Consultant/Sub Cntr A& Address City�n tA^ IJc6Y0�Z7 Phone 8oU l- 3ot� Billable PartyL Address }w, . City h Zip 9Sa,5-- Phone GIS Coordinates:X Y i CONSTRUCTION WORK TO BE PERFORMED: 13 NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDa ❑WELL IDs ❑OTHER IDS TYPE 8#OF WELLBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS a _❑MONITORING ❑HOLLOW STEM DA.OF BOREHOLE_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING CIA: _0 EXTRACTION:Vaporl Water ❑HAMMERIDRNEN. CASING THICKNESS TYPE OF CASING: ❑STEEL 13 PVC ❑ OTHER _O SOIL VAPOR PROBE D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS O NOSE.❑PIPE _O SOIL BORING O PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 Fn _❑INJECTION(to fur So .0z 1 0 HAND AUGER GROUT SPECIFICATIONS _❑OTHER: - ❑OTHER' APPROX BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes Casing Dia: Casing Depth; Boring Ole-- COMMENTS:— NOTE: le:COMMENTS:NOTE: OFFSITE WELLS&BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION MET OD• CHECK ALL THAT APPLY) (.I_#OFWELL(S)TORE D3TR0YED OVER.BOREDIAMETEROF INCHESTODEPTHOF�FT WELLIDs: t 1 � 1- A1W PRESSURE GROUT To DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS_ n+ s� ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE S D: A�1 ERS HOE PIPE ❑MUSHROOM CAP AT e3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS 1 hereby certify that 1 have prepared this application and that the work will be done In accordance With San Joaquin County Ordinances,Rulas and Regulations,and gplieable "On"la�to . Signed �/ ✓ Tilie/Company Print Name 1`)t`TA r1 /i/1 t I A)4s-, Date 10^I O DEPARTMENI USE ONLY RECEIVED SITE MAP IN UNIT IV FILE-SITE ADDRESS WORK PLAN DATED Z'-e, I�Z-- APPLICATION ACCEPTED BY Akf t-tA - DATE ISSUED, AREA 6 ( 1 GROUT INSPECTION BY FINAL INSPECTION BY TL.}{EA(.TH DESTRUCTION INSPECTION BY DATE. .-r.urrreCAVH:F$ COMM ENTSICONDITI ONS: ACCOUNTING ONLY: AID FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3SDz 126X ?S' ° tt- PR# 2900 C-67 WC WAIVER C-67 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-01 G1/1N12 WELLPERMITAPP