Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> s <br /> 4" <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> �Y.- 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION \ <br /> Telephone: (209) 468-3147 Fax: (209) 468-3433 Web:www,s*ciov.org/eh ' <br /> WELL & BORING PERMIT APPLICATIONS y ?,g 1013 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATIO�J� <br /> 9 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I Application a li"evy made to San Joaquin County for a permit to construct and/or install the work described. This application is m d2In,' +`r)cp WSan <br /> Joaqun County Dgvelopment Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Departmekt °Wji <br /> Site Locatwn�►e�^'61th`Street Cross Street E Street City/State Tracy,CA Zip 95376 APN�Gity-&treet <br /> Propwty <br /> Owrw C•fy of 1—Y Address 333 Civic Center Plaza City/State Tracy,CA Zip95376 Phone(209)831-6400 <br /> ertnicon Engineering Servi 4539 N.Brawle Ave.#108 Cit /State Fresno,CA Lic 767888 Phone (559)276-9311 <br /> C-57 Co�rsc>tw ��,5ress Y City <br /> /State <br /> -aw Address City/State Lic Phone <br /> Billable p"Trrtwdcon Engineering Address 4539 N.Brawley Ave.#108 City/State Fresno,CA Zip 93722 Phone(559)276-9311 <br /> i <br /> GIS Ca ewOnwrr N/A Y N/A <br /> t <br /> CQ0,*TRWTYgil4 WORK TO BE PERFORMED: <br /> ❑11*W WMA.OWWMG(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> C1 V: w •.A,IDs <br /> 1 now.. =.e <br /> I rf't }�1 ,,,,fyQRING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> i <br /> _ ' •.« -. ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 1 Water ❑HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> t <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _ Mme.Ozone,❑HAND AUGER GROUT SPECIFICATIONS <br /> _ ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: <br /> tf *FSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> K TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) <br /> 3 • a rw 4e DESTROYED ®OVER-BORE DIAMETER OF 8 INCHES TO DEPTH OF 2 6.5 FT <br /> V*, ..x Ift;,,_tfl 2 and MW-3 ❑PRESSURE GROUT TO DEPTH OF Fr BELOW SURFACE <br /> GPr4_T S+"C -)NS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TRFWW T"a *+ USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(?3 FT) Fr BELOW SURFACE <br /> COMrHrTlt <br /> S iw—" DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I tw.by t>.n/! tar'nave prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,Rules and <br /> Rger�ow wr go swplicable California laws. <br /> SVn.e > Title/Company President/CEO-Technicon Engineering Services, Inc. <br /> prx%fr.ttti '+ •* Williams Date_G�lao.C9 <br /> p DEPARTMENT USE ONLY A <br /> SITE MAP IN i.ft- f FILE-SITE DDRESS l <br /> WORK PLAN <br /> APPUCATNC*v a „ TED BY DATE ISSUED l ��' AREA <br /> GROUT IN<SPFt_rnAv BY FINAL INSPECTION BY DATE <br /> DESTRUCT,ON'V'PECTION/BYY DATE <br /> COMMENTSICLOOMONS: <br /> ACCOUNTING CwLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> �a s 125 x 97�` ��oy G/yam SR# C7. i - <br /> ✓�o (3500) <br /> PR# <br /> (2900) <br /> G57 WC _ WAIVER C-57 LETTER OF AUTHORIZATION 1-0 SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5/09/12 WELL PERMIT APP <br />