Laserfiche WebLink
Sacramento pc 848359 <br />Stockton <br />Lic 680227 <br />Stockton zip 95215 <br />Phone 916-363-9355 <br />Phone 800-511-9300 <br />Phone 800-511-900 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3147 Fax: (209) 468-3433 Web: www.sjqov.orq/eh <br />WELL & BORING PERMIT APPLICATION <br />FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION <br />1 <br />F COPY <br />LOP <br />SITE MITIGATION <br />UNIT IV <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 3032 Waterloo Roac ross Street Sutro Ave City Stockton Zip 95205 ApN 14314030 <br />Pro <br />n <br />p <br />e <br />e <br />r <br />rty <br />Waterloo Food/Fuel Ow Address 3032 Waterloo Road City Stockton Zip 95205 phone 466-5816 <br />C-57 contractor All Well Abndmt Address 9245 Beatty Drive, Sut ity <br />Consultant/Sub Cntr AGE Address 837 Shaw Road City <br />Billable Party AGE-stockton Address 837 Shaw Road City <br />GIS Coordinates: X <br />CONSTRUCTION WORK TO BE PERFORMED: 21 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) <br />El SOIL BORING IDs <br />WELL IDs <br />0 OTHER IDs <br />TYPE & # OF WELL/BORING <br />El MONITORING <br />1 M EXTRACTION: Vapor/ Water <br />0 SOIL VAPOR PROBE <br />INSTALLATION TYPE <br />XHOLLOW STEM <br />0 HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 SOIL BORING 0 PUSH POINT (GP/ CPT) <br />0 INJECTION (i.e .Air Spam, Ozonel 0 HAND AUGER <br />0 OTHER: 0 OTHER: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 10 inch MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: 0 STEEL gi PVC 0 OTHER <br />DEPTH OF GROUT SEAL 85 feet TREMIE TYPE TO BE USED: g AUGERS 0 HOSE 0 PIPE <br />GROUT SEAL PUMPED: AYes 0 No (MAXIMUM FREE FALL DEPTH IS 30 FT) <br />GROUT SPECIFICATIONS Portland <br />APPROX. BORING DEPTH 100 feet BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING M No 0 Yes: Casing Dia: <br /> <br />Casing Depth: Boring Dia: <br /> <br />COMMENTS: <br />NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br />DESTRUCTION WORK TO BE PERFORMED: <br /># OF WELL(S) TO BE DESTROYED <br />WELL IDs: <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE 0 PIPE <br />COMMENTS <br />DESTRUCTION METHOD: (CHECK ALL THAT APPLY). <br />0 OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br />ID PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE <br />0 EXPLOSIVES FROM TO FT BELOW SURFACE <br />O MUSHROOM CAP AT (?.3 FT) FT BELOW SURFACE <br />5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br />I hereby certify that I have prepared his application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and allItable C laws. <br />Signed <br />Print Name William little <br />Title/Companygeologist/AGE <br />Date 11 June <br />DEPARTMENT USE ONLY, <br />SITE MAP IN UNIT IV FILE - SITE ADDRESS :2Y) zoil-re-k)-00 k3 iLiN 1 1 1012 <br />WORK PLAN DATED 2,0 <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION <br />COMMENTS/CONDITIONS: <br />tto• „ <br />Min <br />DATE IS <br />FINAL INSPECTION BY Trtagal DATE 449-1 <br />DATE <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE <br />REQUEST <br />RO # <br />PR # INVOICE <br />,-9() ( $ 125 x ( /1.-c <br />35-1? 5) <br />t rr 6 4/--( a sR# 6.5 fort <br />RO # <br />(3500) <br />PR # <br />(2900) <br />WAIVER /1-)14- C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC NA C-57 V WC <br />EHD 29-01 01/13/12 WELL PERMIT APP