Laserfiche WebLink
aRq"`'�•.o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> a <br /> y 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION <br /> • N o Telephone: (209) 468-3147 Fax. (209) 468-3433 Web:www.siciov.orcllehd UNIT IV <br /> FOR <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <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 Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Location k`Z S Cross Street 1 V�{ City/State S_Vuk�N­Mp� APN <br /> Property r i, IV Q� tL ✓�� <br /> Owner N -� iI ztr Uys Address )0a • Vl V_th City/State {3zPQ�'t Zip °�2�Phone '3l <br /> G� y <br /> C-57 Contractor t- 1 01' Itt Address q�� City/State r1CVh1-c2~Lic_ lPhone <br /> Consultant/Sub Cntr Address W\,Ai" 9- 3t4kLZOL%City/State Psi i Lic Phone <br /> Billable Party ` ` Address Ll City/State I ZIP 9?(OL63 Phone 1 ' <br /> GIS Coordinates:X Y PAYMENT <br /> CONSTRUCTION WORK TO BE PERFORMED: 7 <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> El SOIL BORING IDs 1 2014 <br /> ❑WELL IDs <br /> ❑OTHER IDs SAN JOA01JIM rpWyTM <br /> TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ENVIROMENTAL <br /> HEALTH DEPAATMW <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> _❑EXTRACTION:Vapor/Water ❑HAMMERIDRIVEN 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 ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(.e.Air Soaroe.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: CHEc ALL THAT APPLY <br /> #OFWELL(S)TOBE DESTROYED VER-BORE DIAMETER OF U. . INCHES TO DEPTH OF FT <br /> WELL IDs: 42 t.t,•—I-:- ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br /> GROUT SPECIFICATIONS I 75"' ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS Ej 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,a a licable California laws. <br /> Signed � Title/Company L't a1l EEy�, �e'.'loi=r,t <br /> Print Namd/ t3: i3e,440L Date ellrzla <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED_�A•� � 8 .9-0/t/ _ <br /> APPLICATION ACCEPTED BY (/� �0 -07�-+ ��a✓� DATE ISSUED llifl'Y AREA <br /> GROUT INSPECTION BY /lam FINAL INSPECTION BY DATE 6 sr �Y <br /> DESTRUCTION INSPECTION BY a> ^Pt DATE 6���iY <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 PRI# <br /> $125x ;r'� � ���02 `( 9 SR#(� rJ� <br /> RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 5109/12 WELL PERMIT APP <br />