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2900 - Site Mitigation Program
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PR0515450
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Last modified
6/23/2020 6:38:07 PM
Creation date
6/23/2020 3:48:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
FIELD DOCUMENTS
RECORD_ID
PR0515450
PE
2960
FACILITY_ID
FA0012153
FACILITY_NAME
SOUTH SHORE PARCEL
STREET_NUMBER
0
STREET_NAME
WEBER
STREET_TYPE
AVE
City
STOCKTON
Zip
95202
CURRENT_STATUS
01
SITE_LOCATION
WEBER AVE
QC Status
Approved
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EHD - Public
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�--" • <br /> qc' SAN JOAQUIN COUNTY <br /> %, ?t ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> �e ;f 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209) 468-3433 Web:www.sicIov.orq/ehd UNIT IV <br /> N;p. <br /> <•F o <br /> WELL PERMIT APPLICATION <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 r>a-=I--n-g1t Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> .�y_.�� ,1 t Assessor's 3�� <br /> Well Location �P p Y� Cross Street I✓�N��--r�1 City Ca%tj�C7J Zip 85203 Parcel# t3�-.6-/-V- V I <br /> Property <br /> OwnerVMA/ AddressPO•BDl.�'Igs cityS''%ClezO Zip% 4 Phone# <br /> .WtW lifeP 0 ^"'R• <br /> C-57 Contractor CAY.Ao&M1 UrJn Address 3032.OMEf C19Com— City k6gL&W GgP og 1p qc-z O Lic# /�1,Phone ml(p)w <br /> Consultant/Sub Cntr4gAt.Yf�t.. Address�I-+ lr .E l L.95,OVtb SO-- City�P-AN(LHo(oft Lic# Phonet-q t'4)vaii0"FPID <br /> GIS Coordinates:X ,Y ,Township 1 Range LQ C— Section 10 <br /> WORK TO BE PERFORMED: <br /> 'NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# El OVER-BORE DIAMETER <br /> ❑WELL# 'f0D S SOTAL ❑PRESSURE GROUT <br /> f7J'OTHER 607410, GROUT SPECIFICATIONS <br /> COMMENTS: p�,,,,�, / <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS" /.K w• -rvaut� tfi �l1 <br /> 1' MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4&2 ❑MUL1T11III�PLE SINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS r]!hd1(G ,C PTYPE OF CASING:❑STEEL X PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL*-Afla—kfAT REMIE TYPE TO BE USED❑AUGERS ppb HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH/IIS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS � <br /> ❑OTHER: OTHER: �_lutC> APPROX.BORING DEPTH t'TO� tl"�TD,A❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> �7e CONDUCT OR CASING PROPOSED (if YES.list specifications In commani section) <br /> COMMENTS: ® WaLue ytytrn IAds, �tr.� % AIN b¢. �nvn�•.�.-A lt4w)n jt Cir Ics= in sena- 49er <br /> <d W wwtu> 2avvt, tcvjer VAO rv1 Z.o�t- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable Cplifornia Laws. <br /> Signed ��!•—t.-s-• _ TitlelCompany r%P-6 04- trrS 4 0-r-,17' <br /> Print Name L`s. 3 <C,c+n.£ rJ.r pt Date T`tT f" <br /> , ,,,DEPARTMENT USE ONLY If , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I XX>- " - j °"`^•-"� `^"tet "' <br /> WORK PLAN DATED: f <br /> APPLICATION ACCEPTED BY�y1/1 DATEIS UED �^ AREA <br /> GROUT INSPECTION BY /i t FINAL INSPECTION BY / DATE <br /> DESTRUCTION INSPECTION BY DATE- <br /> COMMENTS/CONDITIONS: illy <br /> ACCOUNTING ONLY: AID# U FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> a o 3 �R- o 5 1 SR#s 90 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2941 1115107 WELL PERMIT APP <br />
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