FIELD DOCUMENTS_PART 2 FILE 2 - Laserfiche WebLink

Home Browse Search

ORIG '11NAL o°'a"utN'"c SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION Telephone:(209) 468-3454 Fax:(209) 468-3433 Web:www.sigov.org/ehd UNIT IV \CIFO� � Eq WELL Sc BORING PERMIT APPLICATION EI6\@y�r/ FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 1� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SUN O 4 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in corn li i&HC--, Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depart 't t�tllR,�►i�ffVltN7"KL HEALTH Site Location ((0 -7-7 440w)a"1 IZI"rCross Street E, (,0u'�c Ate. City zip qr3;0 ARERI �`p�TNI�FC Property \ Owner -1, /L. 5�n.dlo-1- Address 14-777 W-,v('s j( $-*&A_ City "41�eql Zip '15_j)O Phone159-W1 C-57 Contractor fGt cur e- Dn 11in, Address IL-7r Al,,,, uj&,4jA t Lic_ f Phone 5S3o) 661-3 L00 Consultant/Sub Cntr AQGADZS Address 5-50 tlye. A'• S)e- /LT City Falb.++ Lic Phone `26T-ta?�! Billable Party A2c4,-jzS Address 7 r Wehq Do.yCity FDIS-+'r Zip 9'ft 20 Phone 07I GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEWWELL/BORING(CPT,GEOPRQBE,HYDROPUNCH,HAND-AUGER,OTHER) 9 SOIL BORING IDS t-0 3' --ilNote bo 4-�OA" "% Avr,ry -4'-w �w�� Z� Srcapl..ast) ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water 06-AMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _E1 SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL -0 r TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE [&PIPE SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:t9 Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) ❑INJECTION(ie.Air Soarae ozonel❑HAND AUGER GROUT SPECIFICATIONS /V<=�'� _❑OTHER: ❑OTHER: APPROX.BORING DEPTH _❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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 Regulations,and all appli alifornia Laws. Signed Title/Company YG /"t�++a9�/�r7iic9ps5 Print Name Date /11 ` DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS f 2 77 /f'W� . 10.b iJ t C WORK PLAN DATED �q APPLICATION ACCEPTED BY w DATE 1 GROUT INSPECTION BY FINAL INSPECTION BY i E 7 Z DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE G 7 / REQUEST PR# (O 5 $125 x C ��y 1 2 Q 6(z -q- SR# (P 0q _ RO# U 3� 3500 PR# 2900) C-57_ WC !/ WAIVER N�4- C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC -f'