FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

-� SAN JOAQUIN COUNTY .•.0 ENVIRONMENTAL .HEALTH DEPARTMENT LOP • 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION ECM '12oa�':P Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www,s' ov.or leh IV WELL & BORING .PERMIT APPLICATION _ �� r- ; r FOR.WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDUGS 2011 Application is hereby made to San Joaquin County for a permit to construct and/or install the work-described.'This application is made i Joaquin County DevelopmenCTitle,Chapter 9-1115.3,and the Standards of t e San Joaquin County Environmental Health Department"�fRE HEALTH 1 �LIlcx� jj (( /� 3 °' ]PI�}RMIT/SI= IES Site Location Cross Street c1A_p1'f�Jar r i!t�(' City,S t i 1 Zip f.i APN � Property —r ...:. — Owner I t,JC.. C �-- Address Cityt ' Zip Phone C-57 Contractor (� 5-1 - A Address �� '�cn City b1.1`^C4 6!'sur% Lic 5 Phone L/V-lam Consultant/Sub Cntr � ,�G Address r `t�� Grnj :� City :^ L Phone Billable Party IS[�t Ad3 dress - ��i.7 . S�l F,w �f City 5}z r'} Zi S.�1 Phone (I f GIS Coordinates:X. Y CdD7 - CONSTRUCTION WORK TO BE PERFORMED a . . ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ❑SOIL BORING IDs e ❑WELL IDs El OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE' CONSTRUCTION SPECIFICATIONS ' ❑MONITORING ❑HOLLOW STEM RIA.OF BOREHOLE W ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN . CASING THICKNESS W TYPE OF CASING ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) _❑INJECTION i.e.AirSnarge Ozone)❑HAND AUGER GROUT SPECIFICATIONS ' �•-❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE CONDUCTOR CASING❑No❑:Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS: _ c NOTE: OFFSITE WELLS& BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION_METHOD:(CHECK ALL THAT APPLY) _ jj2j OF WELLS TO 13E DESTROYEEf, ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: kj fiV' RESSURE GROUT TO DEPTH OF 9VLJD FT BELOW SURFACE GROUT SPECIFICATIONS -!a ek a-,- kG ❑l EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE c' ❑'MUSHROOM CAP AT(?3 FT) FT BFLow SURFACE COMMENTS , .- `fig . . 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS .,: .rte. I. -. , .- -4. : . r I hereby certify that I have prepared this application and that the work will bedone in accordance with San Joaquin County Ordinances, Rules and Regulations,and all applic le Callforn' laws.• .,A ' , - - - •, I � . - - Signed Title/Company 6pG') 15t. . i Print Name 01 Date— DEPARTMENT USE ONLY. SITE MAP IN UNIT IV FILE-SITE ADDRESS_y�� a (� �©G�/ _ iLF !n P v WORK PLAN DATED APPLICATION ACCEPTED BY _ ,� � � DATE,ISSUED Z 1Z AREA GROUT INSPECTION BY~ f,13,,�,.,.,4,.r FINAL INSPECTION BY r/� _c y DATE _ 2 2 / DESTRUCTION INSPECTION BY k DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# SERVICE RO# PE CODES FEE INFO AMT REMITTED' CHECK# RECV'D BY 'DATE INVOICE REQUEST. PR# 3 T 2 $ lgfx Io # IZSO y 5 t G� , $ 2�i1 . :SR#.t,33^tj 303300 RO# 3500 3416 PR# 2900 C-57 WC WAIVER - - - --C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD29-01 07/28/10 r 1,.. .E WELL.PERWTAPP F 1