COMPLIANCE INFO_2004-2011 - Laserfiche WebLink

Home Browse Search

LOP SITE MITIGATION UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 made in compliance with San Jo uin County Dev to ment Titl Cha ter 9-1115.3, and the Standards of the San Joaqui County Environmental Health Department. Site Location /— tl�O li✓ v O ross Street 5,&0 • City / Zip APN ) -7 OwneProper C- 14 �/ 1-•r � ddress 9,� G✓ City 5��'�� Zip93'� �S�Phon �Op/ 14 C-57 Contractor /eE�li A�r7«%`Z?Address rO f!' W 6 �d CityM*'f-// /Z i4 t 5_14 Phon u 3 Consultant/ r o L"9 << Address // �1�' 8 � " �ity.i��'y��"11% Lic,/�- 4 G hon 8 i 42 5�� 113 6 Billable Party tT��d� /��C�u�City f� �l-a✓ Zip 9� Phone GIS Coordinates: X CONSTRUCTION WORK TO BE PERFORMED: IWNEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) / ❑ SOIL BORING IDs WELL IDS —/ OTHER IDS TYPE & # OF WELL/BORING MONITORING _❑ EXTRACTION: Vapor/ Water _❑ SOIL VAPOR PROBE INSTALLATION TYPE HOLLOW STEM ❑ HAMMER(DRIVEN ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER _❑ OTHER: ❑ OTHER: CONSTRUCTION SPECIFICATIONS it 0 b DIA. OF BOREHOLEZ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: / CASING THICKNESS rek 90 TYPE OF CASING: ❑ STEELPVC [I OTHER DEPTH OF GROUT SEAL Za /! TREMIE TYPE TO BE USED: UGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED:�Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT)_ _ GROUT SPECIFICATIONS _«�� /✓�C/LL/ APPROX. BORING DEPTH %/' '�WBnCfED TRAFFIC BOX OR ASTOVE PIPE ,— DUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia COMMENTS: �I/C G C CI?lic_nti/ /I✓t �/ /��%f� �/. C f_ 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 QE D STROYED OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: �/ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS mL ❑ 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 prep Regulations, and all applicablO Signed Print Name/v lw l L this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and irnia laws. _ Title/Company g-Aw ✓�;W (Ill % 6 L �IiZiC�iQ SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DEPARTMENT USE ONLY a _j -;.40-t- 7*;,- • 1e--"'0- DATE ISSUED ,moi t' -PG✓�— ��2i�� _ FINAL INSPECTION BY - "DATE * DATE att' 0 -Ya SAN JOAOI'!N c n- • PQ�I" SAN JOAQUIN COUNTY Q: a ENVIRONMENTAL HEALTH DEPARTMENT • . — - 600 East Main Street, Stockton, CA 95202-3029 �FORa Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.sigov.orq/ehd LOP SITE MITIGATION UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION 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 made in compliance with San Jo uin County Dev to ment Titl Cha ter 9-1115.3, and the Standards of the San Joaqui County Environmental Health Department. Site Location /— tl�O li✓ v O ross Street 5,&0 • City / Zip APN ) -7 OwneProper C- 14 �/ 1-•r � ddress 9,� G✓ City 5��'�� Zip93'� �S�Phon �Op/ 14 C-57 Contractor /eE�li A�r7«%`Z?Address rO f!' W 6 �d CityM*'f-// /Z i4 t 5_14 Phon u 3 Consultant/ r o L"9 << Address // �1�' 8 � " �ity.i��'y��"11% Lic,/�- 4 G hon 8 i 42 5�� 113 6 Billable Party tT��d� /��C�u�City f� �l-a✓ Zip 9� Phone GIS Coordinates: X CONSTRUCTION WORK TO BE PERFORMED: IWNEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER) / ❑ SOIL BORING IDs WELL IDS —/ OTHER IDS TYPE & # OF WELL/BORING MONITORING _❑ EXTRACTION: Vapor/ Water _❑ SOIL VAPOR PROBE INSTALLATION TYPE HOLLOW STEM ❑ HAMMER(DRIVEN ❑ MUD ROTARY _❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) _❑ INJECTION (i.e .Air Sparge. Ozone) ❑ HAND AUGER _❑ OTHER: ❑ OTHER: CONSTRUCTION SPECIFICATIONS it 0 b DIA. OF BOREHOLEZ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: / CASING THICKNESS rek 90 TYPE OF CASING: ❑ STEELPVC [I OTHER DEPTH OF GROUT SEAL Za /! TREMIE TYPE TO BE USED: UGERS ❑ HOSE ❑ PIPE GROUT SEAL PUMPED:�Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT)_ _ GROUT SPECIFICATIONS _«�� /✓�C/LL/ APPROX. BORING DEPTH %/' '�WBnCfED TRAFFIC BOX OR ASTOVE PIPE ,— DUCTOR CASING ❑ No ❑ Yes: Casing Dia: Casing Depth: Boring Dia COMMENTS: �I/C G C CI?lic_nti/ /I✓t �/ /��%f� �/. C f_ 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 QE D STROYED OVER -BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: �/ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS mL ❑ 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 prep Regulations, and all applicablO Signed Print Name/v lw l L this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and irnia laws. _ Title/Company g-Aw ✓�;W (Ill % 6 L �IiZiC�iQ SITE MAP IN UNIT IV FILE - SITE ADDRESS WORK PLAN DATED APPLICATION ACCEPTED BY GROUT INSPECTION BY DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: DEPARTMENT USE ONLY a _j -;.40-t- 7*;,- • 1e--"'0- DATE ISSUED ,moi t' -PG✓�— ��2i�� _ FINAL INSPECTION BY - "DATE * DATE att' 0 -Ya SAN JOAOI'!N c n- C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 W�ELL PERMIT APP EALTH DEPARTMENT ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # I INVOICE REQUEST PR # SST -4+ 8a 2 � �! I SR#40603 '{ii1 a RO# 3500 PR # 2900 C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 07/28/10 W�ELL PERMIT APP