FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

ep4�l" • SAN .JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT LOP Q. : d 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION �".. P. Telephone(209) 468-3464 Fax: (209) 468-3433 Web:www.s ov.or le UNIT V 9CIF0R�` WELL & BORING PERMIT APPLICATION utl FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION,HUG 18 2011 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Depa�6Wd 4LS/1CTH 1 _ D PERp/SIT/SERVICER Site Location LINOS C tw7r/00 Cross Street \ IGLou + City Zip �S 15 APN og7-100-59 Propert Owner �rneSt- 6i0�h, RCCln(nl Address L(tlF07'c Ir��1�1100 GP city�c,�- �, Zip 05,WS PhonQOi 133) C-57 Contractor 11�� 1 Au l) Address (� fVI B+GL<,K.�(�P City V v' �Lic Phone��50(,L/L1-16/g Consultant/Sub Cntr l t('-e Address � 2 kAw city C`Fo /aA Lic�-PhoneSOO �11-93Cf'� Billable Party ITI� Address l� �i�(W city L �r)tn�G Zip' 1 Phone EOD D/i 5'C�C1 GIS Coordinates:X Y CONSTRUCTION WORK TO BE PERFORMED: ❑NEW WELLJBORING(CPT,GEOPROOE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs ❑WELL IDs ❑OTHER IDS TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: —L]EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL ❑PVC ❑ OTHER _[I SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: I]AUGERS ❑HOSE ❑PIPE _[I SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _0 INJECTION p e.Air 5oaroe.Ozone)❑HAND AUGER GROUT SPECIFICATIONS —[I OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING❑No I]Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS D STRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECK ALL THAT APPLY #OF WELL(S)TO BE DESTgqDYED VER-BORE DIAMETER of S_INC S TO DEPTH OFT WELL IDs: MkJ- - -`i 1U W' PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS1>-6 AIons i/ tf Sq EXPLOSIVES FROM To FT BELOW SURFACE TREMIE TYPE TO BE USED: UGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS 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,andapplicable C lifo�!a laws. Signed 27 i Title/Company (geo)OS/-?t) Print Name t°-la✓l data - -U DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE-SITE ADDRESS y VD 7- Ww4r.,IOo CI-C'oLW WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED t IZr-IJ AREA GROUT INSPECTION BY L\XL�C+ FINAL INSPECTION BY UtAn a-� DATE °) 'h / DESTRUCTION INSPECTION BY DATE COMM ENTS/CON DITI ONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE O# INVOICE �L REQUEST PRR# Z9o2 $12 X 10 12sbro0 335J3 8 2z // SR# 6330.6 Z9o3 3 ,0o RO# 3500 P o0 53$3�s" C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 WELL PERMIT APP